Personal Insurance - Fact Find

Personal Insurance - Fact Find
Brokerage

INTRODUCTION
Applicant 1
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Trading name (if applicable)
Applicant 2
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Trading name (if applicable)
Address

Street Address 1

Street Address 2

CityState / Province

Postal / Zip Code
Email
HOW DO YOU WANT TO PAY YOUR PREMIUMS?
Direct Debit (Your bank account or credit card will be automatically debited until further notice)

FortnightlyMonthlyQuarterlySix monthlyYearly

SECTION 2. CONTENTS RISK
Risk Start Date

DayMonthYear
Renewal Date

DayMonthYear
Cover Type

Residential Home Maxi Sum Insured ReplacementResidential Home Flexi Sum Insured Indemnity
Location Address

Street Address 1

Street Address 2

City

Postal / Zip Code
Have you made any contents related insurance claims within the last 12 months?

YesNo
Type of property where the contents are located?

Owner occupied homeRental propertyOwner occupied home and rentalHoliday homeUnoccupied homeStorageOther
What type of property are the contents located at?
Who uses the contents?

The insuredThe insured and up to 2 unrelated flatmatesMy tenant - single tenant / familyThe insured and my single tenant / familyThe insured and more than 2 unrelated flatmatesMy tenant - multi and unrelatedHoliday home owner and familyHoliday home owner and casual occupants
Does this home have a security alarm?

YesNo
Which type of security systems?

Monitored security systemsUnmonitored security systems
Name of monitoring company
What is the sum insured of your general contents?
What is the sum insured of your specified items?
Total contents sum insured
SPECIFIC ITEMS WITH LIMITS THAT CAN BE INCREASED

This section provides guidance on some of the items of contents with limits that you can increase if you specify a higher value below. This summary does not include all of the limits within the various insurer Residential Contents Policies we may consider. You should not rely on this summary and need to refer to the Final Residential Contents Policy document for the full details of the limits.

The following items are covered up to the limits in this table below:

Item	Limit
Bicycle	$3,000
Camera / Video Camera Equipment	$3,000
Canoe / Kayak, Surf Ski / Board, Paddleboard, Kite / Wind-surfer	$3,000
Jewellery / Watches*	$3,000
Individual coin, card or stamp	$1,000
Collection of coins / cards / stamps	$3,000
Gold / Silver / Bullion or precious metals (in total for any one claim for one or more items)	$1,000
Unset precious or semi-precious gemstones or minerals (in total for any one claim for one or more items) **	$1,000
Worldwide jewellery	$0

* The maximum amount we will pay for any one claim for multiple items of jewellery and watches that are NOT specified will be 15% of the contents sum insured (excluding the specified items sum insured) or $15,000, whichever is the greater.

** The limit for unset precious or semi-precious gemstones or minerals can only be increased in some circumstances. You will need toapply to extend this limit. If we agree to extend this limit, a clause will be added to your policy setting out the terms of the extension.

If you want to insure items in the table above for their full value, please specify each item in the space provided below: The values (and the items themselves) that you specify below will be insured in addition to your ‘general contents’ sum insured above. The total sum insuredis a combination of the general contents and the specified items and the maximum we will pay is the sum insured shown on the schedule.

Items Details

	Item	Description	Amount
1
2
3
4
5
6

What excess option would you like?

$5,000 Excess$2,500 Excess$1,000 Excess$750 Excess$500 Excess$250 Excess (standard)

SECTION 4. BOAT
Type of boat

YachtPowerboatLaunchJetboatOther
Year built
Make, builder and model
Boat name and number
Purchase Price
Purchase date

DayMonthYear
Length
Draft
Beam
Maximum motored speed
Hull material

Details of Engine

	Manufacturer and year	Horsepower	Engine serial No.	Type of fuel
Type of engine (Main)
Type of engine (Inboard)
Type of engine (Outboard)
Type of engine (Auxiliary)

Trailer
Make
Year
Reg No.
Dinghy
Make
Year
Length
COVER REQUIRED

ltem(s)

	Sum Insured ($)
Hull, fixtures and fittings
Sails, masts, spars, rigging
Machinery and inboard motors
Outboard motors
Auxiliary motors
Boat trailers
Dinghy
Clothing
Fishing and sporting equipment
Any other additional equipment / gear

Do you require cover while racing?

Yes (additional premium applies)No
Is the boat is under hire purchase, finance or lease?

YesNo
Please give full details of the interested party.
LOCATION OF THE BOAT
Is your boat?

TraileredMooredOther
Please describe method of storage and location.
Where is it kept when not in use?

StreetGarageDrivewayFront yardBack yardOther
Location of mooring
Type of mooring

MarinaPileSwingOther
Date mooring last lifted (Swing mooring only)

MonthDayYear
Date
Does the mooring meet minimum port or local authority requirements for the size of the boat?

YesNo
Does the mooring meet minimum port or local authority requirements for its conditions?

YesNo
GENERAL DETAILS
Is the boat sound and seaworthy?

YesNo
Do you belong to a boat club?

YesNo
Please provide details of any relevant experience in handling boats, and any boating qualifications for yourself and anybody else operating the boat
Please attach a copy of qualifications to qualify for a premium discount

Cancelof
Please provide details of any theft prevention and security devices on the boat and trailer (if you have an approved security device you qualify for a premium discount).
Are fire extinguishers kept on board?

YesNo
How many?
Is the boat ever used for business or charter purposes?

YesNo
Provide details

SECTION 6. IMPORTANT NOTICES AND DECLARATION
Duty of Disclosure
Subject to any rights you have under the Criminal Records (Clean Slate) Act 2004, the information given is in every respect correct and complete and all material information has been disclosed, whether the information is asked for or not. Material information is information that might influence our decision to insure you and if so on what terms and / or premium. If you have any doubt as to whether a fact is material then it must be disclosed. The duty to disclose all material information occurs prior to the commencement of cover, if the contract is varied and prior to each renewal. Failure to disclose all material information may result in the insurer avoiding your insurance policy. This means your policy would be deemed never to have existed and any claims would not be payable. The information contained in this document shall be the basis of the contract between you and the insurer, and you are willing to accept cover subject to the insurers policy terms, conditions, exclusions and any special terms that the insurer may require.

Privacy Act 2020
The brokerage has collected your personal information in order to evaluate your insurance requirements for the purpose of deciding whether to issue insurance cover and, if so, on what terms. Failure to provide any personal information requested by the brokerage may result in your application for insurance being declined. The brokerage 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 the brokerage that you disagree, the information you supply may also be used by the brokerage to provide you with information about other facilities, products and services. Your personal information is held by the brokerage. In accordance with the Privacy Act 2020, individuals have a right to request access to and correction of their personal information (a fee may be payable) by contacting the brokerage.

Authorisation
You authorise the brokerage 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. You also authorise the brokerage to disclose personal information about you to it’s related companies (as defined by the Companies Act 1993), all it’s present and future contracted insurance product manufacturers and / or authorised representatives for these purposes.
Signature of Applicant(s)

Clear
Date

MonthDayYear
Notes / special instructions:

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Personal Insurance - Fact Find

Applicant 1

Applicant 2

SECTION 1a. HOLIDAY HOME DETAILS

Section 1: House 2 Risk

SECTION 2a. HOLIDAY HOME DETAILS

SPECIFIC ITEMS WITH LIMITS THAT CAN BE INCREASED

GENERAL INFORMATION: VEHICLE 1

VEHICLE 2

GENERAL INFORMATION: VEHICLE 2

DETAILS OF DRIVER

TRAILER, CARAVAN OR HORSEFLOAT

COVER REQUIRED

LOCATION OF THE BOAT

GENERAL DETAILS