Property Insurance Quote Request

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

First Name Middle Name Last Name
E-mail address of Proposer *
Type of Cover *

Fire & Allied Perils Fire & Theft House Holder’s Comprehensive
Optional /Additional Coverage Available (Please indicate)

Theft
I want a quote on:

Building Contents Equipment Stock
Estimated Value of:
State address of premise(s) &/ or item(s) to be quoted
Use of Premises

Private Dwelling Private Dwelling & Commercial Commercial
Construction Material of External Walls

Wood Concrete Plywood Wood & Concrete Pre-fabricated metal Stucco Covintec
Construction Material of Roof

Zinc Concrete Tile Shingles Asbestos Thatch
Type of Building

Bungalow Split Level Elevated
Number of Floors

One storey Two stories Three stories
Estimated age of building
If available, please upload pictures of building.
What is applicant’s interest in insurance of premises?

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

Yes No
Is there any protection?

Yes No
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

DISTANCE

CONSTRUCTION TYPE

USE

FRONT

REAR

RIGHT SIDE

LEFT SIDE