Personal Insurance Home & Contents Questionnaire Step 1 of 4 25% Underwriting Acceptance CriteriaHas the insured had a claim refused, insurance declined, or special conditions imposed on a policy of insurance in the last 5 years?* Yes No If yes, please provide details Has the insured, or anyone permanently residing with the insured, been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?* Yes No If yes, please provide details Is the block of land larger than 20,000sqm?* Yes No InsuredInsured name* First name Middle Name Last Name Date of birth of oldest insured party?* Day Month Year Current insurer? ClaimsHave the insured parties made any home or contents related claims within the past 5 years?* Yes No Claim informationPlease tell us about all the claims made during this period: Acceptance CriteriaIs the property:a) Used for business purposes other than home office or surgery?* Yes No b) under construction, reconstruction or renovation?* Yes No c) in poor condition or poorly maintained?* Yes No e) under any heritage listing/ National Trust listing or order?* Yes No f) used as a hostel, hotel, serviced apartment, boarding house, bed and breakfast or guesthouse?* Yes No g) currently unoccupied or expected to be unoccupied for more than 90 continuous days during the period of cover?* Yes No h) will any part of the property be used for farming or earning an income other than residential rental income?* Yes No If yes, please provide details i) has the land where the building or contents are situated been flooded or inundated by water more than once in the last 10 years?* Yes No If yes, please provide details CoverageOccupancy type*Owner OccupiedRentingWeekender/ Holiday HomeBuilding type*Free standing homeTownhouseTerraceApartment/ FlatSemi-DetachedDuplex/ Triplex/ QuadplexGranny flatNursing home unitIf apartment/ flat/ unit, thenYesNois the building subject to a strata plan?If apartment/ flat/ unit, then What floor are you located on?Type of cover required?*Buildings and contents insuranceBuildings ONLY insuranceContents ONLY insuranceBuildingsHome address* Street Address Address Line 2 City State Post Code AustraliaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Construction DetailsWallsWhat is the main building material that the walls are constructed from?AluminiumBrick veneerConcreteDouble brickFibro/ asbestosHardiplank/ HardiplexMud brickSandwich foam/ EPSSteelStoneStrawVinyl claddingWeatherboard/ woodOtherif other, what materials are the walls constructed of? if other, what materials are the walls constructed of?RoofWhat is the main building material that the roof is constructed from?AluminiumConcreteFibro/ asbestosIron (Corrugated)SlateThatchTin/ steel/ colourbondTilesTimberAge or year built How old is the building or what year was it constructed in?Number of levels123+QualityStandard qualityAbove average qualityTop of the rangeBuilding replacement value? Estimated replacement valueSecurityWhat best describes the security on the property's externally accessible doors?*NoneDeadlocks onlyKey card accessDeadlocks and key card accessWhat best describes the security on the property's externally accessible windows?*NoneNo accessible windowsSecurity bars/ security screens onlyKey operated locks onlySecurity bars/ screens AND key operated locksAlarm security?*NoneMonitored burglar alarmUnmonitored burglar alarm Optional CoverDo you require Electrical or Mechanical Breakdown cover for electrical appliances?*YesNoNote: This is in addition to the burning out of an electrical motorGet help Contents Sum InsuredContents sum insured Excluding Specified Valuables coverWould you like more information about Specified Valuables cover? Yes, please contact me No thank you NOTE: Noting Specified Valuables is easy and cost-effective. If you want to add listed Specified Valuables, please tick this box and we will email you to gather the necessary information.Interested PartiesWill there be any interested parties listed on the policy?* No Yes Please list any interested parties to this property Include details of mortgage holders.Paying monthly?*Monthly payments are available at no additional cost Yes please No thanks Preferred email address for quote?* Duty of disclosureYour duty of disclosure*Before you enter into an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984. If we ask you questions that are relevant to our decision to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. You have this duty until we agree to insure you. If you do not tell us something If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. I have read and I understand my duty of disclosure. EmailThis field is for validation purposes and should be left unchanged.