Insured Details
Insured
ABN
Situation of Insured Property
Mailing Address
Start date for insurance
Property Details
Construction of Walls
Brick
Concrete
Fibro
Timber
Other
Construction of Floors
Concrete
Timber
Other
Construction of Roof
Concrete
Fibro
Iron
Tile
Timber
Other
Year built
Is any part of the building heritage listed?
Yes
No
Cover Required
Mortgage Amount
Name of Mortgagee
Strata Plan No.
Duty of Disclosure Details
Have you had any claims in the last 3 years?
(If yes, please provide details below)
Yes
No
Has the insurance on this risk ever been declined or had special terms imposed?
(If yes, please provide details below)
Yes
No
Are the premises occupied?
Yes
No
Are there any hazards/defects associated with the property? (If yes, please provide details below)
Yes
No
Duty of Disclosure details
Current Insurer
Current Excess
Your Details
Title
Mr
Mrs
Miss
Ms
First Name
Last Name
Job Title
Company
Telephone
Facsimile
Mobile
E-mail
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