Landlords Insurance Quotation Form – For testing "*" indicates required fields Step 1 of 4 25% Insured DetailsFull Legal Name* First Last Date of Birth* DD slash MM slash YYYY Contact Telephone* Email Address* Address* Street Address Suburb Postal Code Policy CoverCommencement Date* DD slash MM slash YYYY Sum InsuredBuilding ($)* Landlords Contents, Fixtures & Fittings ($)* (such as carpet, curtains, light fittings)Rental Income received per week ($)* Is the property managed by a licensed property manager?*SelectYesNoProperty manager details* Insured Property DetailsInsured Property Address* Street Address Suburb Postal Code Year Built* Is property currently unoccupied?*SelectYesNoDwelling Type*SelectFree-standing houseTownhouseHoliday Home / Short termFlat / ApartmentNumber of Levels* Construction* Brick Brick Veneer Timber Concrete Other Please provide details* Roof* Tiled Tin/Iron Slate Other Please provide details* Security* Window locks Dead locks on external doors Bar or grills on windows Alarm Monitored Local Is the property used for business?*SelectYesNoWhat type of business?* Other Interest Parties – MortgageeName Insurance History – During the last 5 years has the applicant had any:Made a claim to insurance company?*SelectYesNoApplication for insurance rejected?*SelectYesNoA policy cancelled by any insurance company?*SelectYesNoSpecial conditions set on your policy?*SelectYesNoRenewal of any insurance policy not offered?*SelectYesNoIncreased excess imposed on your policy?*SelectYesNoIf you have answers YES to any of the above questions, please provide additional information:*Personal History – Has the applicant ever:Been charged or convicted of a criminal offence?*SelectYesNoBeen declared bankrupt?*SelectYesNoWhat is 10 + 8 ?*Spam SecurityPhoneThis field is for validation purposes and should be left unchanged. Δ
