Customer Insurance Declaration Form

Date

Name

First NameLast Name

Select your Required Cover Option

Bedrooms

Rows	Bedroom 1$ Value	Bedroom 2$ Value	Bedroom 3$ Value	Bedroom 4$ Value
Bed - Mattress
Bedroom Suite
Bedside Lamps
Bedside Table/Chest
Blankets/Linen
Carpets/Rugs
Chest of Drawer/Tallboy
Dressing Table
Picture/Painting/Ornament
TV
Wardrobe/Cupboard

Please add any BEDROOM items not shown above and the value of the item:

Loungerooms

Rows	$ Value
Bookcase
Books
Carpets/Rugs
CD's/DVD's/Records/Cassettes
Crystals/Ornaments
Lounge Suite
Lounge - Armchairs
Lounge - Couches
Coffee Tables
Piano/Organ
Keyboard
Computers/peripherals
Picture/Painting/Artwork
Stereo Equipment
TV
Rugs/Carpets
Sport/Gym Equipment
Musical Instruments

Please add any LOUNGE/LIVING ROOM items not shown above and the value of the item:

Hallway

Rows	$ Value
Hallstand
Lamps
Rugs
Table (Occassional, sml)
Picture/Mirror
Ornament

Please add any HALLWAY items not shown above and the value of the item:

Dining Room

Rows	$ Value
Buffet/Sideboard
Carpets/Rugs
Crystal/Display Cabinet
Dining Suite
Glassware/Crockery/China
Liquor

Please add any DINING ROOM items not shown above and the value of the item:

Study

Rows	$ Value
Bookcase
Books
CD Player/Stereo/Speakers
Computer/Peripherals
Computer Chair
Desk
Filing Cabinet
Lamp
Printer

Please add any STUDY items not shown above and the value of the item:

Kitchen

Rows	$ Value
Crocker/China
Cutlery
Electrical Appliances
Kitchen Table/Chairs
Microwave
Pots/Pans
Fridge
Freezer

Please add any KITCHEN items not shown above and the value of the item:

Bathroom/Laundry

Rows	$ Value
Cleaning Tools
Clothes Dryer
Ironing Board
Linen
Linen Basket
Mops/Brooms etc.
Toiletries
Vacuum Cleaner
Washing Machine

Please add any LAUNDRY/BATHROOM items not shown above and the value of the item:

General

Rows	$ Value
Airconditioner Portable
BBQ
BBQ / Webber Portable
Bike - Adult
Bike - Child
Childrens Toy
Clock
Dog Kennel
Garden/Outdoor Setting
Garden Tools
Golf Bag and/or Buggy
Hobbies/Collectibles
Ladder
Lawn Mower
Pool/Billiard Table (please provide full detals below)
Trampoline
Tools/Power Tools
Wheelbarrow
Workbench
Gym/Exercise Equpment

Please add any GENERAL/SUNDRY items not shown above and the value of the item:

VALUABLES: Please list any valuable/antique, curio, jewellery, precious object, artwork, medal, money, coin, stamp collection. Items such as fur, precious or precision item valued at $1,000 or more.

TOTAL VALUE OF EACH SECTION ABOVE TO BE COVERED