Name* First Last Owner Builder Name*Phone Number*Email Address*Job AddressStreet Name & Number*Suburb*Post Code*Job Description*Select oneNew DwellingAllteration / Addition to Existing DwellingRenovationCompletion of Existing ProjectProject Value*Public Liability* $20 000 000 $10 000 000 Is there an Existing Structure?* Yes No Do you want us to quote for the Existing Structure?* Yes No Existing structure replacement value*Will Excavation Exceed 2m?* Yes No Construction* Brick Other Other Construction:*Construction of a Pool* Yes No Do you hold an owner builder permit for this project? Yes No Please provide the owner builder permit number if availableHas there been any previous claims at this site or for any previous owner builder projects? Yes No Approximate Start Date* DD slash MM slash YYYY Will there be any Retaining walls greater than 15 meters in length and/or 1 meter in height?*If yes please provide details in the additional information section. Yes No Will there be work involving piling, shoring or underpinning?*If yes please provide details in the additional information section. Yes No Would you like voluntary workers cover to cover yourself and friends or family who assist on site for no income?* Yes No What injury benefit would you like* $300 per week up to 26 weeks $500 per week up to 26 weeks Any Additional InformationCompletion of existing projectDate work originally commenced DD slash MM slash YYYY Expected date of completion DD slash MM slash YYYY Value of work completed to dateDescription of work completed to dateCurrent Insurance* Yes No Current policy expiry date DD slash MM slash YYYY Have you had previous insurance? Yes No Preferred Method of Contact* Email Phone PhoneThis field is for validation purposes and should be left unchanged. Δ
