"*" indicates required fields Step 1 of 5 20% Insured's DetailsYour Name*Email Property Owner's Name*Property Address* Street Suburb State Post Code Interested Party / Financier Duty of DisclosureHas the Insured ever:Had an insurance policy cancelled, declined, or terms imposed?*SelectYesNoBeen declared bankrupt?*SelectYesNoBeen liable for a civil offence or penalty exceeding $5,000?*SelectYesNoBeen convicted of a criminal offence in the past 5 years?*SelectYesNoBeen involved in a business that became insolvent or entered insolvency or voluntary administration (e.g., liquidation / receivership)?*SelectYesNoIf you answered 'Yes' to any of the questions above, please provide details below, including dates where applicable.*Claims HistoryHas the Insured made any insurance claims in the last 5 years*SelectYesNoPlease describe the recent claims*Date of LossDescription of LossClaim AmountInsurer Add RemoveClick the plus sign to add multiple claims Property DetailsPlease select the sections you wish to cover* Property – Building (replacement value) Business Interruption (loss of rent) Glass (replacement) Public Liability (property owners) Machinery Breakdown Theft (landlord fixtures/fittings) Tenant DetailsTenants' Description - Number of tenants?Select1234567891011121314151617181920Please provide details of the tenants occupation.* Add RemoveClick the plus sign to add details of multiple tenants.Will any part of the building be used as a place of residence?*SelectYesNoIf yes, please specify:*SelectLess than or equal to 49% floor spaceMore than 49% floor spaceProperty DetailsYear Built (YYYY)*Year Last Rewired (YYYY)*Number of Levels/Floors*Is the property more than 50% vacant?*SelectYesNoIs the building heritage listed or has a heritage overlay?*SelectHeritage ListedHeritage OverlayBothDo any of the tenants use deep frying or wok cooking?*SelectYesNoIf so, how many litres in total does it hold?*SelectUp to 10 litersUp to 20 liters40 liters60 litersOtherPlease specify total number of litres*Construction DetailsFloors* Ground - Concrete Ground - Timber Above Ground - Concrete Above Ground - Timber Other Walls* Concrete Brick Metal / Steel Timber Other Roof* Concrete Tiles Iron on Steel Iron on Wood Other Fire Protection* Fire Extinguishers Hose Reels Smoke Detectors - Monitored Smoke Detectors - Non Monitored Other Security Protection Provided* Deadlocks on doors Security fencing Roller shutters Bars on windows Alarm Other If you selected 'Other' for any of the above, please provide details*Does the premises have a sprinkler system?*SelectYesNoSprinkler Type : 100% Coverage*SelectCompletePartialOther Property DetailsWhere is the property located?* Main or suburban street Industrial complex Outside metropolitan, regional or town boundaries Other Sum InsuredProperty - Fire & Specified PerilsBuilding(s) Replacement Value*Landlords Fixtures/FittingsExcessSelect$500$1,000$2,000OtherOther - please specify the excess*Business Interruption - Loss Of RentAnnual Rental Received*Indemnity Period*6 months12 months24 months36 monthsTotal Sum InsuredGlass CoverageExternal / Internal*SelectExternal Glass OnlyInternal Glass OnlyBoth External and Internal GlassGlass Exposure*SelectSingle-frontedDouble-frontedMulti-frontedExcessSelect$250$500OtherOther - please specify the excess*Public Liability CoverageAnnual Rental Recieved*Liability Limit*Select$10,000,000$20,000,000ExcessSelect$500$1,000$2,000OtherOther - please specify the excess*Machinery BreakdownEnter number of unitsOr add unitsDescriptionNumber of unitsValue Add RemoveExample: Air conditioner - 2 unitsExcessSelect$250$500$1,000OtherOther - please specify the excess*TheftSum Insured : Landlords Fixtures/FittingsExcessSelect$500$1,000OtherOther - please specify the excess* Insurance HistoryIs the property currently insured?*SelectYesNoUnknownCurrent insurerExpiry date DD slash MM slash YYYY Required by:* DD slash MM slash YYYY Would you like to upload a copy of the current policy schedule?SelectYesNoUpload policy scheduleMax. file size: 1 GB. Do you wish to provide any additional information?*NoYesAdditional informationPlease tick the box to provide your consent* We draw your attention to the Important Notice accompanying this Application form. You must read the Important Notice carefully. If you do not understand the content of Important Notice, please contact us immediately. If any of the statements in this Application form are untrue, and you have suppressed or mis-stated any facts and/or should any information given by you alter between the date of this Application form and the inception date of the insurance to which this Application form relates you must immediately notify us. You authorise us to collect or disclose any personal information relating to this insurance to any insurer or insurance reference service. Where you have provided information about another individual (for example, a relative, employee or client), you have or you will make the individual aware of that fact and the section in the Policy on "The way we handle your personal information". You agree that you have read and understood this notice by doing any of the following: (a) Signing and returning a copy of this form; or (b) Providing the information requested and returning the form to us; or (c) Providing us with instructions to place the policy. Completed by* Name Contact Number*Date DD slash MM slash YYYY Δ
