Personal Insurance - Fact Find

Personal Insurance - Fact Find
Brokerage

Applicant 1
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Format: (000) 000-0000.
Email
Address
Applicant 2
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Format: (000) 000-0000.
Email
Address
Add additional applicant

YesNo
Applicant 3
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Format: (000) 000-0000.
Email
Address
Add additional applicant

YesNo
Applicant 4
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Format: (000) 000-0000.
Email
Address
Add additional applicant

YesNo
Applicant 5
First Name
Last Name
Date of birth

DayMonthYear
Occupation
Telephone
Format: (000) 000-0000.
Email
Address

Select the Risks to add to this Quote

HomeContentsVehicleBoat

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

What excess option would you like?

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

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

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

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

Rows	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

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)
Date

MonthDayYear
Notes / special instructions:

Should be Empty:

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

Rows	Item	Description	Amount
1
2
3
4
5
6

Rows	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)

Personal Insurance - Fact Find

Applicant 1

Applicant 2

Applicant 3

Applicant 4

Applicant 5

Home 1 Details

Holiday Home 1 Details

Home 2 Details

Holiday Home 2 Details

Home 3 Details

Holiday Home 3 Details

Home 4 Details

Holiday Home 4 Details

House 5 Details

Holiday Home 5 Details

House 6 Details

Holiday Home 6 Details

House 7 Details

Holiday Home 7 Details

House 8 Details

Holiday Home 8 Details

House 9 Details

Holiday Home 9 Details

House 10 Details

Holiday Home 10 Details

SPECIFIC ITEMS WITH LIMITS THAT CAN BE INCREASED

Vehicle Risk

General Information: Vehicle 1

Vehicle 2

General Information: Vehicle 2

Vehicle 3

General Information: Vehicle 3

Details of Driver

TRAILER

TRAILER 2

CARAVAN

HORSEFLOAT

Boat

COVER REQUIRED

LOCATION OF THE BOAT

GENERAL DETAILS