You can always press Enter⏎ to continue
Now create your own Jotform - It's free!
Create your own Jotform
Home-Based-Business Insurance
An insurance package that covers your domestic and business assets, business interruption, domestic legal liability and public & products liability. To apply for a quote please complete all questions.
START
1
Here we go! Let's start with the basics. Are you a new client or existing client of Status Insurance Brokers?
*
This field is required.
New Client
Existing Client
Previous
Next
Submit
Press
Enter
2
*
This field is required.
This will only take a few minutes. Ready to go?
First Name
Last Name
Previous
Next
Submit
Press
Enter
3
Great to meet you! Now, what's your home address?
*
This field is required.
Street Address
Suburb
State
Post Code
Number of Storeys
Previous
Next
Submit
Press
Enter
4
Is this property your primary residence?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
5
Which best describes your situation?
*
This field is required.
My Home Isn't Covered
Insurer Cancelled My Policy
I'm Currently Insured With A Insurance Broker
I'm Currently Insured With A Direct Insurer
Previous
Next
Submit
Press
Enter
6
How soon do you need your quote?
*
This field is required.
To help us prioritise, please provide an honest answer
ASAP - My Insurer Is Cancelling Due To Business Activities Disclosed
Within 2 Business Days
Within 5 Business Days
Within 10 Business Days
ASAP - My Insurer Is Cancelling Due To Business Activities Disclosed
Within 2 Business Days
Within 5 Business Days
Within 10 Business Days
We'll try our absolute best to meet your needs.
Previous
Next
Submit
Press
Enter
7
*
This field is required.
Who is your current Insurer? Please advise latest Insurer if policy was recently cancelled.
When does your policy expire? (DD/MM/YYYY). Please insert today's date if this is a new policy.
How many years have you held Home & Contents Insurance?
Previous
Next
Submit
Press
Enter
8
What type of building is it?
*
This field is required.
House - On Slab/Foundations
House - On Poles
Unit/Apartment/Flat
Villa/Townhouse
Duplex/Triplex/Quadplex
Part of Body Corporate/Strata Title
Semi-Detached
Retirement Village Unit
Nursing Home Unit
Mobile Home
Holiday Home
Relocatable Home
Granny Flat
Caravan
Under Construction
Previous
Next
Submit
Press
Enter
9
How is the home occupied?
*
This field is required.
Owner Occupied - I own & live in the home
Renter - I rent the home to live in
Previous
Next
Submit
Press
Enter
10
How would you describe your home interior & exterior?
*
This field is required.
Standard Quality
Above Average
Top of the Range
Poor Condition/Poorly Maintained
Previous
Next
Submit
Press
Enter
11
When was your home originally built?
*
This field is required.
Previous
Next
Submit
Press
Enter
12
Has your home ever been re-wired or re-plumbed?
*
This field is required.
If 'Yes', please advise year for each.
Previous
Next
Submit
Press
Enter
13
Do you have any of these at your home?
*
This field is required.
Back to Base Burglar Alarm
Local Sounding Burglar Alarm
Fire Extinguisher/s
Fire Blanket/s
Connected to Town Water
Tank Water
Safe
Security Bars/Screens on all External Windows
Key Operated Window Locks on all External Windows
No Accessible Windows
Deadlocks on all External Accessible Doors
Keycard Access on all External Accessible Doors
Electric Gates/Security Fencing
CCTV System Installed
Hard Wired Smoke Detectors
Previous
Next
Submit
Press
Enter
14
Does your home feature any of these?
*
This field is required.
Inground Swimming Pool
Above Ground Swimming Pool
Spa
Ducted or Split System Heating/Cooling
Solar Panels
Shed
Granny Flat
Land Exceeds 2 Hectares
Previous
Next
Submit
Press
Enter
15
Do you share your home with any of the following?
*
This field is required.
Partner
Kids
My Staff Work at the Property
Family Members
Less Than 3 Unrelated People
More Than 3 Unrelated People
More Than 6 Livestock
Agistment of Other People's Animals
Horses Used for Non-Personal Use
Previous
Next
Submit
Press
Enter
16
Do you have a mortgage or loan at this property?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
17
If you'd like, we can match our quotes to your existing policy?
Please upload your policy schedule showing details of cover and we can compare apples for apples.
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
18
When would you like cover to start?
*
This field is required.
Please note: cover will be subject to a 72 hour exclusion period for cyclones, floods (where optional cover for flood is taken), grassfires and bushfires. Please refer to the Product Disclosure Statement provided by your Account Manager for full details.
-
Date
Day
Month
Year
Previous
Next
Submit
Press
Enter
19
Applicant 1
*
This field is required.
Legal Entity to be insured
Full Name
Date of Birth (DD/MM/YYYY)
Phone
Email Address (so we can contact you about your quote)
Previous
Next
Submit
Press
Enter
20
Applicant 2
Legal Entity to be insured
Full Name
Date of Birth (DD/MM/YYYY)
Phone
Email Address
Previous
Next
Submit
Press
Enter
21
Building Information
*
This field is required.
Please let us know your building details so that we can suggest the right cover for you.
Brick Veneer
Double Brick
Concrete/Besser Block/Cement
Asbestos
Non Asbestos Fibro
Hebel
Wood/Timber/Weatherboard
Hardiplank/Hardiflex
Mud Brick
Steel/Metal
Vinyl Cladding
Stone/Sandstone
Sandwich Foam/EPS (Expanded Polystyrene)
ACP (Aluminum Cladding Panel)
Mixed >75% Brick/Concrete/Iron on Steel
Mixed
Other
Brick Veneer
Double Brick
Concrete/Besser Block/Cement
Asbestos
Non Asbestos Fibro
Hebel
Wood/Timber/Weatherboard
Hardiplank/Hardiflex
Mud Brick
Steel/Metal
Vinyl Cladding
Stone/Sandstone
Sandwich Foam/EPS (Expanded Polystyrene)
ACP (Aluminum Cladding Panel)
Mixed >75% Brick/Concrete/Iron on Steel
Mixed
Other
What is the construction of the walls?
Concrete
Cement Tiles
Clay/Terracotta Tiles
Colorbond
Wood/Timber
Asbestos
Iron/Steel/Aluminum on Steel
Iron/Steel/Aluminum on Wood
EPS (Expanded Polystyrene)
Asbestos
Slate
Thatch
Other/Mixed (Non Combustible)
Other/Mixed (Full/Partial Combustible)
Concrete
Cement Tiles
Clay/Terracotta Tiles
Colorbond
Wood/Timber
Asbestos
Iron/Steel/Aluminum on Steel
Iron/Steel/Aluminum on Wood
EPS (Expanded Polystyrene)
Asbestos
Slate
Thatch
Other/Mixed (Non Combustible)
Other/Mixed (Full/Partial Combustible)
What is the construction of the roof?
Yes
No
Yes
No
Is the home on more than 2 hectares (5 acres)?
Backs/front onto or surrounded by bushland/farmland
1 street back or equivalent distance from bushland/farmland
2 to 5 streets back from bushland/farmland
Nowhere near bushland/farmland
Backs/front onto or surrounded by bushland/farmland
1 street back or equivalent distance from bushland/farmland
2 to 5 streets back from bushland/farmland
Nowhere near bushland/farmland
How close is the property located to bushland/farmland?
Yes
No
Yes
No
Is the property Heritage Listed?
Accidental Damage including Flood Cover
Defined Events including Flood Cover
Accidental Damage including Flood Cover
Defined Events including Flood Cover
Please select a coverage type.
Previous
Next
Submit
Press
Enter
22
Property Cover Required
*
This field is required.
Building Sum Insured (Replacement Value)
Personal Contents Sum Insured (Replacement Value)
Yes
No
Yes
No
Would you like cover for non business/personal items away from the home (portable contents)?
How much would it cost to replace all of your business contents/stock/equipment?
Yes
No
Yes
No
Would you like to include cover for business contents/stock/equipment?
Previous
Next
Submit
Press
Enter
23
Is the property used for business purposes other than a home office?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
24
What business activities are conducted from the home?
*
This field is required.
Please describe business activities in full, including parts of the property used as a business premises, or for buying, selling or storing business products, services or equipment.
Huge
Large
Normal
Small
Ok
Ok
Previous
Next
Submit
Press
Enter
25
Will the business occupy more than 20% of the building floor area?
*
This field is required.
YES
NO
Previous
Next
Submit
Press
Enter
26
*
This field is required.
Yes
No
Yes
No
Would you like cover for Business Interruption?
Estimated annual turnover from the business activities?
Yes
No
Yes
No
Would you like cover for Public & Products Liability?
How many employees do you have (including yourself)?
Yes
No
Yes
No
Do customers/suppliers visit your premises?
Previous
Next
Submit
Press
Enter
27
Only complete this section if you require Public & Products Liability cover, otherwise please proceed to the next question.
Yes
No
Yes
No
Do you sell/manufacture/apply any products onto a clients skin or hair?
Yes
No
Yes
No
If 'Yes', do you purchase all products from suppliers within Australia?
Yes
No
Yes
No
If 'Yes', Do the products meet Australian Standards?
Yes
No
Yes
No
Do you provide any medical services?
Yes
No
Yes
No
Do you sell any products?
Previous
Next
Submit
Press
Enter
28
Acceptance Criteria
*
This field is required.
Yes
No
Yes
No
Is the home under construction/renovation?
Yes
No
Yes
No
Is the property to be demolished in the next 12 months?
Yes
No
Yes
No
Has the property or its grounds been affected by flooding, bushfire, wildfire or grassfire?
Yes
No
Yes
No
Is the property used as a hostel, bed and breakfast, guesthouse or short-term letting (e.g. AirBnB/Stayz)?
Yes
No
Yes
No
Is the property currently unoccupied or expected to be unoccupied for more than 60 continuous days during the period of cover?
Previous
Next
Submit
Press
Enter
29
Have there been any home or contents related claims made within the past 5 years?
*
This field is required.
If 'Yes', please confirm 1) property address, 2) if there are any outstanding repairs, 3) a brief description of the loss, 4) date of claim, 5) insurer that the claim was made through, and 6) total $ settlement amount of claim
Huge
Large
Normal
Small
Ok
Ok
Previous
Next
Submit
Press
Enter
30
Have there been ANY business related claims made within the past 5 years?
*
This field is required.
If 'Yes', please confirm 1) a brief description of the loss, 2) date of claim, 3) insurer that the claim was made through, 4) total $ settlement amount of claim, and 5) preventative measures taken
Huge
Large
Normal
Small
Ok
Ok
Previous
Next
Submit
Press
Enter
31
Has any insurer in respect of any insurance policy held by you, your partner or anyone to be insured:-
*
This field is required.
Yes
No
Yes
No
Refused to renew/cancelled or terminated a policy?
Yes
No
Yes
No
Refused/Rejected a claim under a policy of insurance?
Yes
No
Yes
No
Imposed special conditions under the policy?
Yes
No
Yes
No
Ever been convicted of any criminal offence ?
Yes
No
Yes
No
Have you ever been declared bankrupt or put into receivership or liquidation?
Previous
Next
Submit
Press
Enter
32
Do you have any other additional information you would like to tell us or attach including photos, valuations, etc?
Drag and drop files here
Select files to upload
Max. file size
: 10.6MB
Browse Files
Cancel
of
Previous
Next
Submit
Press
Enter
33
By getting a quote you agree to our Financial Services Guide, "Your Duty of Disclosure" and our Privacy Policy
*
This field is required.
Yes
Yes
Please confirm you agree & understand your Duty of Disclosure/Disclosure Obligations
Yes
Yes
Please confirm you have read & understand our Financial Services Guide and Privacy Policy
Previous
Next
Submit
Press
Enter
34
Important Features
*
This field is required.
Rank which is most important to you (in the order of importance – 1 is most important)
Price of the Insurance
Monthly Payment Option
Lower Excess
Higher Excess to Reduce Overall Premium
The Insurer’s Claim Paying Record / Service
Australian Insurer
Previous
Next
Submit
Press
Enter
35
How did you hear about us?
*
This field is required.
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
35
See All
Go Back
Submit