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First Name:Last Name:

Email:Phone:

Insured or Company Name:

Date of Birth:

Start Date:

Insured Property Address:

Postal Address:

Number of bedrooms:

Number of bathrooms:

Number of stories:

If an apartment, what floor level is it situated on?:

Is the property on an acreage? If so, how many?:

What year was the property built?:

What material are the external walls built with?

Roof Type:

Additional Security (alarms, deadbolts, window locks etc):

Is there a pool/spa/sauna?:

Yes

No

Building Sum Insured (excluding land):

Contents Sum Insured (any items over 10k may need specifying):

Excess:Please Select$300$500$1000

Is the property managed by a licenced agent?

Yes

No

Do you ever occupy the premises?

Yes

No

Short term/Long term tenants?

Short term

Long term

Is the building a strata property?

Yes

No

Theft by tenant cover?

Yes

No

Loss of rent cover?

Yes

No

If loss of rent cover is required, what is the annual income amount?:

Any claims in the last 3 years?

Yes

No

Details of any claims within the last 3 years (if any):

Interested Parties (mortgagee):

Do you provide any extra services/activities as part of your guests stay at the premises: