Household Insurance Request Form
Please provide brief details of the type of Household Insurance you require and we will contact you to complete our detailed analysis of the risk. Once we have issued our documentation to you and completed a risk review we will approach Insurer's on your behalf for terms. The completion or return of this form is not a confirmation or request for cover it is a means of contact to commence our review of your requirements. If you have an IMMEDIATE cover requirement please phone our office on 99297155 9-5pm weekdays. We welcome the opportunity to provide a quotation. Click for Location Map and Directions

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IMPORTANT:Please read YOUR DUTY OF DISCLOSURE What you must tell the insurer.

Insured Name


Effective date cover is required:

Details of property to be insured:

Located in (Number/Street)
Located in (Suburb/Town)
Located in (State)
Located in (Postcode)
Is the property Heritage listed? Yes No
Does it meet relevant cyclone standards? Yes No
Does the property have a Pool and/or Spa? Yes No
Does the property have a Jetty and/or Pontoon? Yes No
Does the property have a Tennis Court? Yes No
Is the Property well maintained and structurally sound and secured against wind and rain? Yes No
Does it have reticulated water? (city/town supply) Yes No
Approx. year that home was built
Approx. year that home was renovated
What is the construction of the dwelling? (external walls)
What is the roof of the dwelling? (material)
What Fire Brigade service is available to the property?
Type of Dwelling?
How is the property occupied?
If you are the landlord, what is the weekly rent? $ (Type 'Nil' if not applicable)

Amounts to be insured:

The home (building) $
Preferred building policy excess
The contents  $
Preferred contents policy excess
Special risks (incl. away from premises) Special risks cover is an optional extension to your household insurance policy and is available only when the contents are insured



Specified jewellery


Mobile phones

$ (not for business use)

Portable computers

$ (not for business use)

Safe deposits


Video cameras

$ (not for business use)

Other specified items total

(typically, items in excess of $500 each in value will need to be specified for cover away from home)



Unspecified valuables

$ (typically items under $500 each will not need to be specified)

Security details:

Is the property in a Neighborhood Watch area? Yes No
Are you a Neighborhood Watch member? Yes         No
Do all external windows have  ... standard locks? ... or         key locks?
Do all external windows have  ... security screens, bars, grills or aluminium rollover shutters? ...         Yes No
Does the home have external louvre windows? Yes No
If yes, are they fitted with bars or grills? Yes No
Are all external doors fitted with

Double-key deadlocks

Single-key deadlocks or security doors

Standard locks

Do all external sliding doors have ... Patio bolts and/or security doors?

Standard locks only?

There are no external sliding doors

What burglar alarm/s are installed? Monitored alarm system

Audible local alarm

No alarm system

Is there a safe installed? Yes No
Please make any other comments you think relevant regarding home security.

Details of insured party/ies:

Name 1. 2.
Birth date 1. 2.
Retired Yes No Yes No
Pensioner Yes No Yes No
Do you have Domestic help? Yes No Yes No

Your claims history:

How many years since you have made a claim on a home, contents or special risks insurance policy? (Type 'N/A' if not applicable)
How many claims in last 5 years? (Type 'Nil' if not applicable)
Please list any claims in the last 5 years including brief detail, amount claimed and approximate date of claim
What is the name of your current insurer for this property? (Type 'N/A' if not applicable)
What is your mortgage provider/s name 1st 2nd

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