Household Goods In Storage Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Policy Due Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Storage Facility Details
Name of storage facility
Type of Storage Unit
Please Select
Concrete
Roller Door
Unit number (ID)
Address of storage facility
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Security at Facility
Please Select
Nil
Monitoring/Alarm
Fire Security System/Alarm
Secure Access/Entry
Other
Period of cover (from date/to date)
Sum Insured
$
Description of goods stored:
Duty of Disclosure
Rows
Yes or No
Has the insured suffered any loss during the past 5 years from any of the events against which they wish to insure?
Yes
No
Has the Insured ever had insurance cancelled, declined or any special conditions imposed?
Yes
No
Has the Insured been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property in the last 5 years?
Yes
No
Has the Insured been declared bankrupt and not discharged within the last 12 months?
Yes
No
Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about and that you know or should know may affect the Insurer’s decision to accept the insurance?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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