Domestic Fact Find - Over50
  • Domestic Fact Find

  • Select the risks
  • Introduction

  • Applicant 1

  • Date of birth
     - -
  • Applicant 2

  • Date of birth
     - -
  •  -
  • Are you a trustee?
  • Trustee 1

  • Date of birth
     - -
  • Trustee 2

  • Date of birth
     - -
  • Home Risk Section

  • Home 1: Details

  • Risk Start Date
     / /
  • Have you made any house (excluding contents) related insurance claims within the last 5 years?
  • Is the home on a lifestyle block or farm?
  • How many self-contained units are at this location?
  • Will any of the units cost less than $300,000 to rebuild?
  • (These amounts will be each unit’s sum insured unless you specify a different amount)

  • What type of building is the main home?
  • How is the home used the majority of the time?
  • Is this home part of a multi unit or Body Corporate complex?
  • Does this home have a monitored smoke or heat detector?
  • Has this home been fully re-wired since 1945?
  • Does this home have any scrim walls?
  • Has the Historic Places Trust placed any restrictions or preservation orders on this home?
  • Are there any entries against the certificate of title for this home?
  • Please note:

    Identified exposures affecting a property will be noted against the certificate of title (and noted within the LIM). An example would be an entry in relation to Section 71 of the Building Act 2004, or Section 36 of the Building Act 1991 or any Section 72, 28 or 51 notices.

  • Is any form of business run from this home?
  • Which form of business?
  • Is there a mortgage on this home?
  • Landlord Extension (only available to full time tenanted houses). Do you require this extension?
  • The sum insured amount should represent the cost of rebuilding the existing home and any self-contained unit(s) (including all improvements at your property).

    Calculator: Sum Sure (corelogic)

  • Rows
  • Holiday Home 1: Details

  • How often do you and your family occupy the holiday home?
  • Is the holiday home leased out on a short term basis?
  • Is this holiday home leased out via website / book a bach / other advertising?
  • Do your immediate neighbours of this property occupy their homes full time?
  • Is the house in a built up area?
  • Do you arrange for anyone to mow your lawns and empty your letter-box?
  • Does it have an alarm, window locks or deadlocks?
  • When you do not occupy your holiday home, do you turn off your outside water supply?
  • When you do not occupy your holiday home, do you turn off all power at the switchboard?
  • Is your holiday home exposed to water inundation from any man made or natural water ways? (including: drains, creeks, rivers, beaches and similar)
  • Add Home?
  • Home 2: Details

  • Risk Start Date
     / /
  • Have you made any house (excluding contents) related insurance claims within the last 5 years?
  • Is the home on a lifestyle block or farm?
  • How many self-contained units are at this location?
  • Will any of the units cost less than $100,000 to rebuild?
  • (These amounts will be each unit’s sum insured unless you specify a different amount)

  • What type of building is the main home?
  • How is the home used the majority of the time?
  • Is this home part of a multi unit or Body Corporate complex?
  • Does this home have a monitored smoke or heat detector?
  • Has this home been fully re-wired since 1945?
  • Does this home have any scrim walls?
  • Has the Historic Places Trust placed any restrictions or preservation orders on this home?
  • Are there any entries against the certificate of title for this home?
  • Please note:

    Identified exposures affecting a property will be noted against the certificate of title (and noted within the LIM).  An example would be an entry in relation to Section 71 of the Building Act 2004, or Section 36 of the Building Act 1991 or any Section 72, 28 or 51 notices.

  • Is any form of business run from this home?
  • Which form of business?
  • Is there a mortgage on this home?
  • Landlord Extension (only available to full time tenanted houses). Do you require this extension?
  • The sum insured amount should represent the cost of rebuilding the existing home and any self-contained unit(s) (including all improvements at your property).

    Calculator: Sum Sure (corelogic)

  • Rows
  • Holiday Home 2: Details

  • How often do you and your family occupy the holiday home?
  • Is the holiday home leased out on a short term basis?
  • Is this holiday home leased out via website / book a bach / other advertising?
  • Do your immediate neighbours of this property occupy their homes full time?
  • Is the house in a built up area?
  • Do you arrange for anyone to mow your lawns and empty your letter-box?
  • Does it have an alarm, window locks or deadlocks?
  • When you do not occupy your holiday home, do you turn off your outside water supply?
  • When you do not occupy your holiday home, do you turn off all power at the switchboard?
  • Is your holiday home exposed to water inundation from any man made or natural water ways? (including: drains, creeks, rivers, beaches and similar)
  • Contents Risk Section

  • Risk Start Date
     / /
  • Have you made any contents related insurance claims within the last 12 months?
  • Type of property where the contents are located?
  • Who uses the contents?
  • Does this home have a security alarm?
  • Which type of security systems?
  • Click here to use the calculator: House Contents Calculator

  • SPECIFIC ITEMS

  • If you would like to insure items 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.  Some items will require valuations.

  • Rows
  • Vehicle Risk Section

  • Vehicle 1: Details

  • Type of use:
  • Cover Required:
  • License Type
  • Please tick:
  • Vehicle security
  • Is the vehicle parked in a locked garage overnight?
  • Comprehensive cover options

  • Do you want to restrict drivers to two persons over the age of 25 years to reduce premiums? (Note: an additional excess will apply to drivers not named)
  • Do you want to exclude drivers under 25 years of age and further reduce premiums? (Note: This is only available where the main driver is over 25 years of age)
  • Tick the excess required
  • Vehicle 1: General Information

  • Is the vehicle petrol turbo-charged or supercharged?
  • Is the vehicle registered in a name other than yours?
  • Is the vehicle under finance or lease?
  • Is the vehicle already damaged or have any defects?
  • Is the vehicle modified in any way? (A modification includes (but is not limited to) changes or enhancements to the: engine, exhaust system and suspension, panels or paint work, size and type of wheels and / or size of tyres)
  • Do you have another vehicle?
  • Vehicle 2: Details

  • Type of use:
  • Cover Required:
  • License Type
  • Please tick:
  • Vehicle security
  • Is the vehicle parked in a locked garage overnight?
  • Comprehensive cover options

  • Do you want to restrict drivers to two persons over the age of 25 years to reduce premiums? (Note: an additional excess will apply to drivers not named)
  • Do you want to exclude drivers under 25 years of age and further reduce premiums? (Note: This is only available where the main driver is over 25 years of age)
  • Tick the excess required
  • Vehicle 2: General Information

  • Is the vehicle petrol turbo-charged or supercharged?
  • Is the vehicle registered in a name other than yours?
  • Is the vehicle under finance or lease?
  • Is the vehicle already damaged or have any defects?
  • Is the vehicle modified in any way? (A modification includes (but is not limited to) changes or enhancements to the: engine, exhaust system and suspension, panels or paint work, size and type of wheels and / or size of tyres)
  • Driver Details

  • Have you or any person who may drive the vehicle had any accidents or losses in the last 5 years?
  • Have you or any person who may drive the vehicle have any mental or physical condition or impairment that could affect their ability to drive?
  • Have you or any person who may drive the vehicle had any special conditions imposed on a motor policy?
  • Had a driving licence suspended, cancelled or any special conditions imposed?
  • Have you or any person who may drive the vehicle accumulated 51 or more demerit points in any two year period?
  • This part requests information on the previous insurance history of your vehicles.

  • Have any of the vehicles proposed for insurance been comprehensively insured during the last 3 years?
  • TRAILER, CARAVAN OR HORSE FLOAT, MOTORCYCLE

  • Please tick box
  • Where is it kept at this address?
  • Boat Risk Section

  • Boat: General Details

  • Type of boat
  • Purchase date
     - -
  • Rows
  • Cover Required

  • Rows
  • Do you require cover while racing?
  • Is the boat is under hire purchase, finance or lease?
  • Boat: Location

  • Is your boat?
  • Where is it kept when not in use?
  • Type of mooring
  • Date mooring last lifted (Swing mooring only)
     - -
  • Does the mooring meet minimum port or local authority requirements for the size of the boat?
  • Does the mooring meet minimum port or local authority requirements for its conditions?
  • Boat: General Information

  • Is the boat sound and seaworthy?
  • Do you belong to a boat club?
  • Are fire extinguishers kept on board?
  • Is the boat ever used for business or charter purposes?
  • Questionnaire Section

  • Have you or any members of your family, or any other person or entity to be covered by this insurance

  • Had any losses in the past 5 years (regardless of whether a claim was made or not)*
  • Ever had any insurance declined, cancelled, renewal refused, terms or conditions imposed or claim declined?*
  • In the past 10 years been bankrupt, and/or been through the No Asset Procedure*
  • Ever been engaged in any criminal activity or had any criminal convictions, acquittals or have any criminal prosecutions pending? (The information sought by this question is subject to the rights set out in the Criminal Records (Clean Slate) Act 2004.)*
  • Had a driving licence suspended, cancelled or special conditions imposed?*
  • Ever been aware of any damage from flooding, landslip or earthquake at any address relating to this insurance*
  • Is there any further information likely to affect this insurance?*
  • Important Notices and Declaration Section

  • 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.    

    Recieving Information from us
    As a client of OverFiftys Insurance Brokerage you will receive ongoing material from us such as renewal information, endorsement notices and letters from your insurer as part of our service to you. We will email this to you unless your preferred method of receiving this type of communication from us is by post.

  • Date*
     - -
  • Should be Empty: