Landlords Insurance

Landlords Insurance Application Form

Please fill out all sections accurately to help us process your insurance application efficiently.
Application Name
Product
Your Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Mobile Number
Format: +61 400000000.
E-mail
example@example.com
Street Address
Suburb
State
Postcode

Property Type
Insured Address
Suburb
State
Postcode
Building Sum Insured
Contents
Property Manager
Company name
Rent
Per week
Mortgagee/Interested Party
Lender

Year Built
Roof Construction
Please provide a description
External Walls
Please provide a description
Cladding
% of Cladding
Cladding Material
Security Alarm
All Windows Key Locked
All Windows Bars and Grills
External Door Deadlocks
External Patio Bolts

Client Consent – General Insurance

I understand my broker may receive a commission from the insurer for arranging, renewing, or varying my insurance.

- Commission is usually 5–20% of the base premium.
- It is paid by the insurer, not added on top of my premium.
- It is included in the premium shown on quotes and invoices provided to me.

This commission covers the broker’s services in sourcing, arranging, and managing my insurance.

This is a legal requirement under the Corporations Act 2001 (specifically the conflicted remuneration provisions in Part 7.7A) and upcoming Quality of Advice reforms.

I consent to my broker receiving this commission.
Name

First NameLast Name
Signature
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Should be Empty: