Name* First Last Insured name (The name of the property owner) if different from above.*Email Address*Phone*Address of the Display Home* Street Address Address Line 2 City State Postcode Year Built*Construction of external walls*Construction of the roofWhat is the construction of the floors?* Concrete Timber Other Please StateNumber of StoriesIf two stories, what is the construction of the 2nd floor?Security on propertyDeadlocks* Yes No Key Window Locks* Yes No Local Alarm* Yes No Back To Base Alarm* Yes No Building Sum insured including fixtures & fittings*Is flood cover required?* Yes No Annual rental income*Any claims/losses?* Yes No Does the building contain any Greenboard?* Yes No Does the building contain any Cladding?* Yes No If yes please provide type*What percentage of your building is foam construction?* 0% More than 0% but less than 15% 15% but less than 30% More than 30% In the last 5 years, has the insured had any insurer decline a claim or proposal, cancel or refuse to renew a policy, or impose special terms, conditions or restrictions on a policy?* Yes No In the last 5 years ever been placed in receivership or liquidation or been declared bankrupt?* Yes No In the last 10 years, has the insured been convicted of, or had any penalties imposed, for any crimes involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?* Yes No Is a signed lease agreement in place as at the inception date of this quote/policy?* Yes No How long is the signed lease agreement for*If no when will it be signed? DD slash MM slash YYYY Is there a mortgagee?* Yes No Is so please advise their nameDo you engage or intend to engage non-clerical contractor, subcontractors, or staff from labour hire firms to perform work under the sole or partial direction of you at the premises?* Yes No Postal Address- Please advise for our records Street Address City State Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman 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 RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall 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 Any other Comments?CAPTCHA Δ
