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HOLIDAY HOME INSURANCE QUOTE FORM
Ten Seventy Pty Ltd t/a/ Reef Insurance Brokers is an Authorised Representative (AR # 1285127) of United Insurance Group (UIG) AFS Number 327131
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1
YOU HAVE A DUTY OF DISCLOSURE OBLIGATION
*
This field is required.
Ok, so before we start we need to tell you some things... Yes, it's boring, but it’s important and we need to do this - it only takes a minute. YOUR DUTY OF DISCLOSURE Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. NOTE: You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that: • reduces the risk they insure you for; or • is common knowledge; or • the insurer knows, or should know; or • the insurer waives your duty to tell them about. IF YOU DO NOT TELL THE INSURER SOMETHING If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. DUTY TO NOT MAKE A MISREPRESENTATION NOTE: if you are applying for a new consumer insurance contract, renewing a consumer insurance contract or varying an existing consumer insurance contract, which is an insurance policy obtained wholly or predominately in relation to personal, domestic or household insurance purposes, you must answer the specific questions asked by the insurer truthfully and accurately. In answering those questions, you must tell the insurer all information that’s known to you and that a reasonable person would be expected to provide in answer to the questions. APPLYING FOR A NEW CONSUMER INSURANCE CONTRACT OR VARYING AN EXISTING CONSUMER INSURANCE CONTRACT. • You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). • Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. • Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. • Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. • If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. • If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.
I / we agree.
I / we don’t agree
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2
When do you want your policy to start?
*
This field is required.
We can’t back date cover, but we can change a start date. If you are not sure - choose today. We can sort this out later.
-
Date
DD
MM
YYYY
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3
Who is the Owner of the property?
*
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Individual/s
Company
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4
Company Name:
if required
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5
Company ABN:
Not sure? Leave this blank and we can look it up for you later.
if required
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6
What is the property owners name/s.
If the property is jointly owned, please note all names.
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7
What is the property address
that you are insuring?
*
This field is required.
Street Address
Street Address
Suburb
State
Post Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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8
Do you have a postal address?
Leave this blank if you don,t have a seperate postal adress.
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9
What is your phone number?
*
This field is required.
Area Code
Phone Number
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10
Email:
*
This field is required.
We need this so we can email you your quote/s.
example@example.com
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11
What type of cover do you want for the property?
*
This field is required.
Note: Accidental Damage is the highest level of cover, where as Defined events offers a lesser level of cover.
Holiday Home & Contents - Accidental Damage
Holiday Home & Contents - Defined Events
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12
What is the occupancy
type of the property?
*
This field is required.
Tick any that apply
Owners Exclusive Holiday Home
Tenanted - Short Term
Managed Holiday Let
AirB&B
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13
How is the property managed?
Self managed
Property manager (real estate agency)
On site management
Other
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14
Please tell us about the AirB&B arrangements at the property?
I.e: do you meet and greet your guests personally & how often do you have guests stay.
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15
How much do you want to insure the Building for?
*
This field is required.
This is the entire replacement cost to rebuild your home in today’s figures to the same level of quality. Don’t forget to add on the pool cost or shed cost if you have them.
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16
You’re doing great! How much do you want to insure your Contents for?
*
This field is required.
Don’t forget to take into account all of your possessions such as clothes, your shoe collection, crockery, linen, kitchen stuff, man cave or shed items ... all your bits and pieces etc. It’s amazing how much this can all add up to...don’t leave yourself short.
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17
Would you like cover for Specified Items?
*
This field is required.
These are valuable items like jewellery, artwork, rugs & collections or sets. Most policies limit the amount you can claim for these items unless you specify them. Hint: as an example if a wedding & engagement ring ‘set’ is worth more than $5k together - you should consider specifying them. Likewise a ‘collection’ of paintings or your beloved racing bicycle etc.
Yes
No
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18
Great choice! We need a description of the Specified Item/s & their values please?
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19
What is the oldest property owners Date of Birth?
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20
Is the property owner
retired?
*
This field is required.
Yes
No
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21
What type of building is your property?
*
This field is required.
Free standing single story house on slab
Free standing single story house on poles/stumps
Unit / Apartment / Villa / Townhouse
Double story house
Duplex / Triplex / Quad
Other
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22
What is the construction of the walls of the property?
*
This field is required.
Tick all that apply if the walls are a mixture of the below options.
Double Brick
Blockwork
Brick Veneer
Wood / Timber
Fibro / Asbestos
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23
What is the construction of the floor of the property?
*
This field is required.
Concrete slab
Wood / Timber
Concrete & Wood (Double Story)
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24
Now we just need the construction of the roof please?
*
This field is required.
Concrete
Wood / Timber
Colour bond
Steel / Aluminum
Other
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25
Great...does your property have any of the following security features?
Please tick all that apply.
Deadlocks on all external doors
Deadlocks on some external doors
Keyed window locks on all windows
Keyed window lock on some windows
Security screens on all windows & doors
Security screens on some windows & doors
Patio bolts on sliding doors
Alarm - local
Alarm - monitored
Swipe card access to building
24/7 Onsite Management
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26
What year was your property built?
*
This field is required.
Not sure? An estimated year is fine.
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27
Has the property ever been re-wired and / or re-roofed?
Yes
No
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28
Great! Please tell us when?
Please let us know the year & whether it was re-roofing or re-wiring
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29
Does the property have any of the following?
Please tick all that apply?
Pool
Heritage Listing
Property is over 5 acres in size
Elevator
Jetty / Pontoon
Tennis court
Solar Panels
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30
Is the property financed?
*
This field is required.
E.g.: Is there any type of Mortgage on the Property?
Yes
No
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31
Financier to be noted on your policy?
E.g.: NAB or Bendio Bank etc.
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32
Is the property well maintained & free from existing damage?
*
This field is required.
Yes
No
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33
Please tell us about the pre-existing
damage?
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34
Has the property owner made any damage claims in the past 5 years?
*
This field is required.
Yes
No
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35
Almost there... please tell us about this property’s claims in the past 5 years?
Date, value of claim, description or type of claim.
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36
Has the property owner ever been refused insurance or had conditions or special terms imposed on an insurance policy in the past 5 years?
*
This field is required.
e.g. imposed additional excess or reduction in cover due to unfixed damage or maintenance requirements.
Yes
No
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37
Please tell us about any conditions or imposed terms from Insurers on the property owners insurance policies in the last 5 years?
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38
Has the property owner ever been declared bankrupt?
*
This field is required.
Yes
No
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39
Has the property owner been convicted or charged with a criminal offence in the past 5 years?
*
This field is required.
Yes
No
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40
Criminal history details of the property owner in the past 5 years.
Ok, so please provide a few details. I.e.: type of charge and year etc.
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41
What excess would you like on your Contents?
*
This field is required.
Choosing a higher excess can reduce your premium.
Standard
$1000
$2000
$2500
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42
What excess would you like on your Building?
*
This field is required.
Choosing a higher excess can reduce your premium.
Standard
$1000
$2000
$2500
$5000
$10,000
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43
Well done, you're finished! Before you hit that submit button please tell us how you heard about us?
A Friend
Yellow Pages
Local Google search
Facebook
Existing client
Other
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