Prestige Home and Contents Insurance Questionnaire

Please complete the following form with as much detail as possible to enable us to get the best possible quotation and insurance solution for your requirements. When completed please submit by clicking the submit button at the bottom of the form. Your personal broker will be in contact very shortly. Thank You.

Policy Period 12 months From: To:
Client Information Please complete with as much details as possible
Name Insured:
Situation to be Insured:
Insured’s age/Date of birth:
Insured's Email Address:
Location address:
Occupation and employer details:
 
Sum Insured Please complete with as much details as possible
Home & Contents Coverage
Building Sum Insured: $ Deductible:  Minimum $500        $1,000      $2,500
Contents Sum Insured: $ If higher deductible required, please state $
Valuable Articles Coverage (in addition to general contents)
Jewellery Sum Insured: $ No. of items: Most Expensive Item: $
Fine Arts Sum Insured: $ No. of items: Most Expensive Item: $
Other Valuable Articles (category of valuable and sum insured) Other 1 $
Other 2 $
Other 3 $
(Note: A Valuable Articles Profile is to be completed should the total Jewellery sum insured be greater than $250,000)
Risk Details Please complete with as much details as possible
External Construction:  Brick         Wood        Concrete
Roof Construction:  Iron         Tile           Slate
Type of Residence  House       Unit
 Primary Residence   Tenanted

 Investment Property               

 Holiday House

How often visited?
Year of construction:
Is the residence currently occupied?

 Yes   

 No

If No, when will it be?
Is the residence Heritage Listed?  Yes           No
If the residence was built prior to 1970, has it been: Re-wired  Yes           No Re-plumbed  Yes      No
Re-roofed  Yes           No    
Is the residence in the course of construction or renovation or are they planned in the next 12 months?  Yes       No
If Yes, type and cost:
Newly Built Homes: Has all work been completed with a compliant Certificate of Occupancy issued (where required)?  Yes        No
If No, what remains outstanding?
Security Please complete with as much details as possible
Deadlocks – All access doors  Yes           No
Keyed Window Locks  Yes           No
Burglar Alarm  Yes           No If Yes, type:  Monitored        Local
Smoke Detectors  Yes           No If Yes, type:  Monitored        Local
Safe  Yes           No If Yes, type:  Fixed      Freestanding
Make/Model/Cash Rating if known: 
Is the safe connected to a Burglar Alarm?  Yes           No
Other Security:

Loss History Please complete with as much details as possible
i. Has the Proposer and/or the Insured had any circumstances that occurred in the last five years that could have given rise to a claim under a household insurance policy whether insured or not?  Yes           No
If Yes, please give details (including type of loss, dates and amounts paid):

ii. Has the Proposer and/or the Insured ever been refused insurance (new or renewal), had insurance cancelled or cover rejected?  Yes           No
iii. Has the Proposer and/or the Insured been charged or convicted of a criminal offence in the last ten years (with the exception of traffic offences)?  Yes           No
iv. Has the Proposer and/or the Insured been declared bankrupt in the last seven years?  Yes           No
If Yes to question (ii), (iii) or (iv), please give full details:

Cover Extensions (Please tick if required) Please complete with as much details as possible
 Flood Coverage (Note: If flood cover is offered, additional premium applies)
 Personal Liability Coverage
 Deluxe Home Business Property Cover (Note: A separate Home Business Quotation Sheet will need to be completed)
General Information Office Use ONLY
Present Underwriter:
Present base premium: $
General comments:

This document does not constitute an offer of cover. A quotation based on information contained herein will be forwarded to you.

In submitting a copy of this quotation sheet, we declare on behalf of the proposer/insured, that the information contained in this quotation is true and correct as advised to us. We acknowledge that the insurer relies upon this information in its determination of whether to offer insurance.

 

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