Householders/Landlords Questionnaire
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Advice Required - Quotation
Cover Note
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Year
1. Applicant Details
Applicant 1
Name
Date of Birth
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Year
Over 55 & Retired?
Please Select
Yes
No
Phone Number
-
Area Code
Phone Number
Mobile Number
Email
Do you currently hold insurance with AIG Direct or IAL?
yes
no
If yes please select appropriate
AIG Direct
IAL
Applicant Details
Applicant 2
Name
Date of Birth
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January
February
March
April
May
June
July
August
September
October
November
December
Month
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2
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Day
Please select a year
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Over 55 & Retired?
Please Select
Yes
No
Phone Number
-
Area Code
Phone Number
Mobile Number
Email
Other information
Situation of Risk:
Postcode:
Bldg. Approx. Age
Postal address if different from above:
Postcode:
Current Insurer:
Policy No.
Current Broker:
Expiry Date:
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January
February
March
April
May
June
July
August
September
October
November
December
Month
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1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2020
2019
2018
2017
2016
2015
2014
2013
2012
Year
Policy Cover:
Please Select
Defined Events
Accidental Damage
Landlords
Prestige
Period of Insurance:
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2. Sum Insured
Size of Building (Sqm):
Building $:
Content $:
Specified Valuables in the Home:
Please Select
Yes
No
Specified Valuables / Amount
Item
Amount
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Item 10
Total Amount $:
Personal Valuables outside the Home:
Please Select
Yes
No
Specified Items / Amount
Item
Amount
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Unspecified Items:
Please Select
Yes
No
Sum Insured $:
Limit any one item $:
Tenant Default:
Please Select
Yes
No
Landlords Insurance: Weekly Rentals:
Malicious damage by tenant:
Please Select
Yes
No
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3. Insured Property Details
Dwelling Type:
Please Select
Domestic Home
Holiday Home
Unit
Town House
Duplex
Flat
Occupant Type:
Please Select
Owner Occupied
Tenant
Other (please specify)
Other, please provide details:
Construction:
Please Select
Double Brick
Other (please specify)
Other, please provide details:
Fire protection:
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Optional Coverages
These coverages are not automatically included under this policy. If you would like to include any of these coverages please select 'Yes'.
Loss of rent
Yes
No
Flood cover
Yes
No
Would you like to reduce your premium by electing a higher Policy Excess?
Yes
No
Additional Questions
Has a residential tenancy agreement for less than 3 months been entered into?
Yes
No
Has a bond equivalent to 4 weeks rent been lodged with the appropriate State Body?
Yes
No
Has a tenancy application form been completed by each occupant who will reside at the property?
Yes
No
Is rent currently in arrears or has rent been in arrears in the last 2 months?
Yes
No
Is the property under a contract of sale?
Yes
No
Is the property undergoing renovations?
Yes
No
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4. Burglary Protection
Burglary protection
Yes
No
Deadlocks on all external doors
Keyed window locks on all windows
Bars or grills on all accessible windows
Electronic surveillance key or card to common areas
Live in manage / caretaker
Safe or other system (please describe)
Back to base alarm
Local alarm system
Is the property on more than 10 acres
Is the property used for business? If yes, specify below.
Is the property occupied?
Will the home be unoccupied for more than 60 days?
Others:
Business type (if "yes" from the above)
Interested Parties
Mortgage
Name
Address
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History
Has any insurer in respect of any insurance policy held by you or your partner
Yes
No
(a) Refused to renew/calcelled or terminated a policy?
(b) Refused a claim or required an increased premium under the policy?
(c) Imposed special conditions under the policy?
(d) Have you ever been convicted of any criminal offence or been declared bankrupt?
(e) Have you had any Claims in the past 5 years?
If YES to any of the above, please give details below.
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Additional Information:
Please provide additional information here:
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