AVONHEAD INSURANCE BUYERS GROUP APPLICATION

Are you the property owner

If not, who do we contact with regard to Insurance eg. Landlord or Property Manager

Customer Name (eldest policy holder)

First NameLast Name

Date of birth

Customer Commencement Date

Date

Home Phone Number

Area CodePhone Number

Mobile Phone Number

Area CodePhone Number

Email Address

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is your home on more than 10,000 sq metres of land? If so call George on 029 4367432 to discuss a Rural Insurance Policy

If 'Yes" please call George on 029 43 67 43 2

Have you made any house (excluding contents) related claims within the last 12 months?

What is the Sum Insured of your home - THIS IS IMPORTANT - a professional valuation should be instructed

Sum Insured advice

TGN recommends using a professional valuer to demonstrate due diligence in the estimation of the sum insured as the requirement to use 'Sum Assured' rather than 'Total Replacement' puts a lot of responsibility upon the property owner - the majority of property owners will most likely be under insured. There are factors such as demolition costs, disposal, construction inflation (particularly after major events), consent and professional fees that mean that building will be in most cases more expensive than expected, so we advice ering on the side of caution. TGN Advisers does not provide advice on values for 'Sums Insured', this is the responsibility of the property owner. In order to help clients feel comfortable with their level of cover we have negotiated a special deal with a highly respected and experienced valuer Mark McSkimming of Bayleys Valuation Services of only $500 for a full valuation of your home - we highly recommend taking up this offer by giving Mark a call on 027 434 3695 or emailing him on mark.mcskimming@bayleys.co.nz even if you only do this to establish a baseline valuation you would never be sorry to have done this.

A starting point is to use a Cordell Calculation for the rebuild cost of your home - https://sumsure.corelogic.co.nz/#/products/8/profiles/219

Does this home have a monitored smoke or heat detector?

What is the main type of home?

Is this home part of a body corporate?

If it is the you may be doubling up on cover

What is the approximate size of the home in Square Metres? Include attached garages and self-contained units NOT sheds or outdoor buildings

Sq Metres

What year was this home built?

Are there any entries against the certificate of title for this home and noted within LIM?

Is any form of business run form this home? If so, what type of business?

Is there a mortgage on this home? If so, which bank and how many mortgages?

Has your House sustained any earthquake damage?

If 'Yes' please complete questions below if 'No' move down to the Declaration Questions at the bottom of the form

Technical Category (TC) of Land on which this property is situated

Find the Category here https://mylandzone.canterburymaps.govt.nz/#/

Was the Home built after the February 2011 Earthquake?

When did you purchase this property?

DayMonthYear

Who did you purchase the property from?

Did the Home/Land suffer ANY Earthquake damage between September 2010 and February 2011?

If you answered 'Yes' to Question 6, please attach a copy of the Scope of Works detailing the repair to the Home/Land This can be sourced from EQC and/or the insurer If you answered 'No' to question 6, please go to the last question in the form

Please detail the damage that occurred at this property (to the Home and/or other structural improvements to the Land). If the Home is built on a concrete pad, you must specifically detail the extent of the damage to the concrete pad.

Is there any unrepaired damage to the Home and/or other structural improvements to the Land? If you answer 'Yes' to this Question, please attach a copy of the Scope of Works detailing the repairs required to the Home/Land. This can be sourced from EQC and/or the insurer. If you answered 'No' to Question 8, please go to Question 'Has the Insurer commenced repair work?' below

Who was the insurer (other than the EQC) between September 2010 and February 2011?

What was the policy number?

Has the EQC and/or the Insurer accepted a claim for the damage?

Has the EQC and/or the Insurer agreed to carry out repairs?

Has the EQC commenced repair work?

When are repairs (organised by EQC) due to or have been completed?

DayMonthYear

Has the Insurer commenced repair work?

When are repairs (organised by the Insurer) due to or have been completed?

Who carried out the repairs? Please tick

Other

Is there any unrepaired damage to the Home and/or other structural improvements to the Land?

Has the Owner (past or present) received or opted for a cash settlement from the EQC or the Insurer?

Has the Owner (past or present) carried out or organised to carry out any of the repairs to the Home/Land themselves?

If you have purchased the Home (that existed at the time of the Earthquake events), have you discussed or agreed with the previous Owner that you will receive any funds from any insurance claim made by the previous Owner?

If you answered ‘Yes’ to Question 15, please provide full details of the discussion/agreement below. If you have a written agreement, please send a copy to george@tgn.co.nz

Declaration Questions

Have you or any members of your family, or any other person or entity to be covered by this insurance: 1. In the past 2 years had more than 2 losses; or in the past 2 years made claims totalling more than $2,500?

Please provide details

2. Ever: Been aware of any damage from flooding, landslip, or earthquake at any address relating to this policy; or, Had any insurance declined, cancelled, renewal refused, terms or conditions imposed or claim declined; or, Been engaged in any criminal activity or had any criminal convictions, acquittals or have any criminal prosecutions pending? (The information sought by this question is subject to the rights set out in the Criminal Records (Clean Slate) Act 2004.)

Please provide details

In order to proceed with this insurance cover application you will need to provide confirmation of the following authorisation and declaration statements :

Authorisation and Privacy Statement

1. You authorise TGN to give to and obtain from other Insurance Companies, Insurance Brokers, the Insurance Claims Register Ltd or any other party any information relating to this or any other insurance held or previously held by you, and any claim(s) made by you, and any information you have provided now or previously for the purpose of payment
2. TGN has collected your personal information in order to evaluate your insurance requirements for the purpose of allowing a selection of insurance companies to decide whether to issue insurance cover and, if so, on what terms. Failure to provide any personal information requested may result in your application for insurance being declined.
3. TGN has also collected your personal information in order to monitor and service your ongoing general insurance requirements, conduct market research, data processing and statistical analysis. Unless you notify TGN that you disagree, the information you supply may also be used by TGN to provide you with information about other facilities, products and services.

Have you read and understood the authorisation statements ?

4. Your personal information is held by TGN. In accordance with the Privacy Act 1993, individuals have a right to request access to and correction of their personal information (a fee may be payable) by contacting TGN Investments Limited at .
5. TGN will provide information on the insurer financial strength rating prior to any policy issuance.

Declaration

I/We declare that the information I/we have provided to TGN and any subsequent Insurer within this proposal, application or declaration form is in every respect complete and correct, whether received or provided verbally, electronically or printed and in relation to this property shall be the basis of the contract between me/us and the Insurer, and I am/ we are willing to accept cover subject to the Insurer's policy conditions and any special terms they may require.

I/We authorise TGN or the subsequent Insurer to give and obtain from other Insurance Companies, Insurance Brokers, the Insurance Claims Register Limited or any other party any information relating to this or any other insurance held or previously held by me/us and any claim made by me/us.

You declare that subject to any rights you have under the Crimincal Records (Clean Slate) Act 2004, the information given is in every respect correct and complete and all material information has been disclosed to us.

Have you read and understood the declaration statement?

Applicant 1 Full Name

First NameMiddle NamesLast Name

Signature Applicant 1

Date

DayMonthYear

Applicant 2 Full Name

First NameMiddle NamesLast Name

Signature Applicant 2

Date

DayMonthYear

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