Property Insurance Quote Request

Property Insurance Quote Request
Name of Proposer (in full)*

First NameMiddle NameLast Name
E-mail address of Proposer*
Type of Cover*

Fire & Allied PerilsFire & TheftHouse Holder’s Comprehensive
Optional /Additional Coverage Available (Please indicate)

Theft
I want a quote on:

BuildingContentsEquipmentStock
Estimated Value of:
State address of premise(s) &/ or item(s) to be quoted
Use of Premises

Private DwellingPrivate Dwelling & CommercialCommercialOther
Construction Material of External Walls

WoodConcretePlywoodWood & ConcretePre-fabricated metalStuccoCovintecOther
Construction Material of Roof

ZincConcreteTileShinglesAsbestosThatchOther
Type of Building

BungalowSplit LevelElevatedOther
Number of Floors

One storeyTwo storiesThree storiesOther
Estimated age of building
If available, please upload pictures of building.
What is applicant’s interest in insurance of premises?

Security/ProtectionMortgageOther
Is there any wooden construction or combustible material less than 10 yards from building to be insured?

YesNo
Is there any protection?

YesNo
Please explain
Adjoining or adjacent building (if any): What is the distance separating the premises to be insured from the adjacent building? What are the construction type and use of the adjacent building?

Adjoining Buildings