Residential Strata Insurance Step 1 of 6 16% Name of person completing this form(Required) First Last Role/ relationship(Required) Phone(Required)Email(Required) Name of Holding Insurer Period of InsuranceCover is required for the period specified belowFrom date DD slash MM slash YYYY To date DD slash MM slash YYYY Claims HistoryHave you had any claims in the past 5 years?(Required) No Yes Please email a claims history for the past FIVE years to firstname.lastname@example.org Building DetailsBuilding name Building addressPlease provide the full address of the property including state and postcode Number of lots/units Estimated year of build Number of floors above ground Number of basement levels Is more than 20% of your building (by floor area) used for commercial purposes? Yes No Are there any known defects? Yes No Describe construction materials used for external walls Describe construction materials used for floors Describe construction materials used for roof Any EPS panelling and or aluminium composite panelling?(Required) No Yes How many stand-alone buildings are there? Year of latest valuation? Has a certificate of occupancy and a strata certificate been issued? Are there any driveways or common areas shared with another strata plan? Are there solar panels or glass atriums on the roof? Are there any planned or ongoing building works (alterations, additions or renovations) in excess of $250,000? How many units are used for short-term letting? Fire ProtectionList all fire protection measures in place at the building None Fire extinguishers Fire hydrants Fire/ smoke alarms Hose reels Sprinklers - All areas Sprinklers - Car parks Sprinklers - Car parks and common areas Unknown FacilitiesNumber of liftsNumber of car stackersNumber of pools/ spasNumber of playgroundsNumber of gymnasiumsNumber of tennis courtsIs the property located directly adjacent to, or does the property contain: a lake, pond, river, canal, ocean or waterway? No Yes Does the property include a jetty, wharf, pontoon or marina? No Yes OccupancyIs the property fully occupied? Yes No If no, please provide details of occupancy Type of occupancy on the ground floor? Residential Commercial Garages Strata DetailsOwners Corporation Number What is your Owners Corporation type?(Required) Common Property ONLY Community Association Community Corporation Neighbourhood Association Owners Corporation Cluster Plan Consolidated Plan Is the property managed by a strata company? Yes No Interested PartyDo you wish to note an Interested Party? No Yes Details of interested party Insured PropertyBuilding Sum Insured% of Building Sum Insured to insure for Loss of Rent? 15% 20% 25% 30% Is cover required for floating floorboards? Yes No Sum insured for Liability to Others? $0 $20,000,000 $30,000,000 $50,000,000 Sum insured for Fidelity Guarantee? $0 $100,000 $200,000 $250,000 Sum insured for Death of Voluntary Workers? $0 $100,000 $200,000 $300,000 Sum insured for Office Bearers Legal Liability? $0 $100,000 $250,000 $500,000 $1,000,000 $2,000,000 $5,000,000 $10,000,000 $20,000,000 Percentage cover for Catastrophe Insurance 0% 15% 30% Are you aware of any claims made or circumstances which may result in claims being made against a Committee Member or their predecessors in their capacity as members of the committee or governing body?(Required) No Yes Duty of DisclosureHave you ever had insurance declined, cancelled, or special conditions imposed, including special excesses?(Required) No Yes Has the cover under your current policy been limited or restricted in any way?(Required) No Yes Please provide details of limitations or restrictions Duty of disclosure(Required) I have read and I understand my 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.Untitled EmailThis field is for validation purposes and should be left unchanged.