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Personal Information
Title
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Mr
Mrs
Miss
Ms
First Name
Last Name
Date of Birth (DD/MM/YYYY)
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Gender
Male
Female
Marital Status
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Separated
Divorced
Married
Cohabiting/Partnered
Single
Widowed
Your City
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Policy Details
Inception Date:
Expiry Date:
Cover Type:
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Accidental Damage
Defined Events
Limited Defined Events
Landlords Insurance
Is this quote for `Landlords insurance` ?
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Yes
No
Current Insurance
Do you currently have insurance for this property?
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Yes
No
What is your current Insurance premium?
Who is your current insurance with?
Location
Suburb:
State:
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NSW
VIC
QLD
SA
WA
NT
TAS
ACT
PostCode:
Building & Construction
Building Type:
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Single Storey House
Multi Storey House
Townhouse
Unit on ground level
Unit above ground level
Security Unit
Other
Walls:
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Brick
Brick Veneer
Fibro
Weatherboard
Timber/Wood
Other
Occupancy:
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Owner Occupied
Rental (insured rents from owner)
Unoccupied
Holiday home/Weekender
Year Built:
Year Last Rewired:
Connected to town water?
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Yes
No
Please enter the amount of insurance required for...
Building
Contents
Personal Property
Amount:
Type:
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Replacement
Indemnity
Excess:
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0
50
100
250
500
1000
Unspecified:
Specified:
Highest value of single item:
Excess:
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0
50
100
250
500
1000
Unspecified:
Specified:
Highest value of single item:
Excess:
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0
50
100
250
500
Domestic Workers Compensation
Domestic Workers Cover
No of Employees:
Security
Double keyed deadlocks on all external doors
Key window locks on all windows
Window grills/bars on all windows
24 hr security person/concierge
Security card/security pad access to floor
Unit at least 2 floors above ground
Securitel/Landline
Security Intercom
Back to base alarm
Local alarm
Fixed Safe
Other Details
Neighbourhood Watch area?
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Yes
No
No of claims/losses in last year:
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Nil
1
2
3
4
5
6
7
8
9
10
> 10
No of claims/losses in last 3 yrs:
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Nil
1
2
3
4
5
6
7
8
9
10
> 10
No of claims/losses in last 5 yrs:
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Nil
1
2
3
4
5
6
7
8
9
10
> 10
No of burglaries experienced by
you at this address in the last 5 yrs:
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Nil
1
2
3
4
5
6
7
8
9
10
> 10
Insured Date Of Birth:
Insured is retired
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