Household Quote
Personal Information
*
Salutation
Mr
Mrs
Ms
Dr
Prof
*
First Name
*
Last Name
*
Street Address
*
Suburb
*
State
NSW
QLD
Vic
SA
WA
ACT
*
Post Code
*
Phone Number
*
Mobile Number
*
Email Address
Building Details
Construction Details
*
Type of Home
House
Townhouse / Villa
Unit / Flat
Holiday Home
*
Wall Constuction
Brick
Timber
Fibro
Concrete
Mixed
*
Floor Construction
Erthen
Timber
Concrete
Mixed
*
Roof Construction
Iron
Timber
Concrete
Tile
Other
Age of Building
Approx Size (Square Meters)
No of Bedrooms
1
2
3
4
5
6 or more
No of Bathrooms
1
2
3
4
5
6 or more
Security Details
Door Security
Deadlocks
Latchlocks
Padlocks
No Locks
Window Security
Keylocks
Bars
Grills
None
Alarm Security
Local Alarm
Back to Base - Dialler Type
Back to Base - Securitel Type
No Alarm
Cover Details
Building
Contents
Sums Insured :
Sum Insured
Highest Value Item
Specified Valuables :
Jewellery :
Fine Art :
Wine :
Insurance History
*
Insurance History
Yes
No
Proposal or Renewal Declined or Special Terms Imposed
Been Charged or Convicted of a Criminal Offence in last 5 years
Any claims in last 5 years
Any other facts that may affect an insurer's assessment
*
Current Insurer
*
Due Date
*
Total Premium
*
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