Domestic Insurance Application Form

Personal Assets Insurance Quote Request Form
What would you like a quote for?*

House/Rental PropertyCar/Caravan/MotorcyclePersonal ContentsBoat/Personal Watercraft
Primary Contact Details*

First NameLast Name
Email*
example@example.com
Phone Number*
Date of Birth*

DayMonthYear
Occupation*
Postal Address*

Street Address

Suburb

CityRegion

Post Code

Home Insurance
Address of Property*

Street Address

Suburb

CityState / Province

Post Code
Current insurer (if insured)
Water Supply*

Reticulated Water Supply (Town)Tank/Bore
What type of home is this?*

Freestanding HouseSemi-detachedFlat/UnitApartmentBody Corporate
Is this home fully self-contained? (Self-contained means that the home has its own functional kitchen and bathroom facilities)*

YesNo
How many self-contained dwellings are to be insured by this policy?*
How many self-contained dwellings are there in the building?*
What is the main building material for the exterior walls of the dwelling?*
Number of Storeys:*
Year of Construction:*

Home Insurance Continued
Floor Area

Please provide the floor area of:
The home including all levels, attached garaged, conservatory and developed basement*
SQM
Any detached garage and outbuildings (over 10sqm each)
SQM
Decking
SQM

Home Sum Insured
Click here to visit the Cordell Sum Sure calculator and work out your sum insured.
What is the estimate of the likely cost to rebuild the home and domestic outbuildings in today's prices? (Excluding GST)?*
This should include any increased policy limits for retaining walls and recreational features, such as any tennis court and/or permanent fixed swimming pool or permanently fixed spa pool including its ancillary equipment and/or pump(s).
The standard policy wording is extended to cover retaining walls up to $75,000 and recreational features up to $75,000.
Do you wish to apply for cover above the levels shown for retaining walls and recreational features?*

YesNo
If 'Yes' to the above question, please provide details of the items (eg. construction materials, dimensions, condition and age of each structure) along with the likely cost to rebuild them:
Special Features' Sums Insured

Within the Home Sum Insured, the following items are covered if they have a replacement cost of the stated limit or less.
Do you need to increase these limits, or does the property have any other special features for which you would like cover under this policy?*

YesNo
If 'Yes' to the above, please provide details of the items (e.g. construction materials, dimensions, condition and age of each structure) along with the likely cost to rebuild them:
Special Feature + Sum Insured
Total Sum Insured

The Total Sum Insured is the sum of the Home Sum Insured and any Special Features Sums Insured (above).
A) Home Sum Insured*
B) Special Features Sums Insured
Total Sum Insured (A + B, excl GST)*
This is the maximum payable to repair or rebuild your home.
If the estimated cost to rebuild the home and domestic buildings exceeds $2m and/or the floor area of the home exceeds 500 sqm, has a valuation for Insurance Purposes been completed for the home in the last 4 years?

YesNo

Policy Limits
Do you wish to apply for cover above these limits?*

YesNo
If 'Yes' to the above question, please give details (description of item, value & valuation number if applicable)
Policy Excess
Do you wish to consider higher excesses than the standard $250 (for a reduced premium)?

+$150+$400+$750
Sum Insured
What is the total cost of replacing the general contents at today's prices (excluding specified items listed above)?*
Does the general contents sum insured include any individual painting, picture or work of art that exceeds $25,000 in value?*

YesNo
If ‘Yes’, please advise the name of artist, name of work, value and details of most recent valuation:

Boat & Watercraft Insurance
Current insurer (if insured)
Years of boating experience*
What type of craft are you insuring?*
Make*
Eg. Stabicraft
Model*
Eg. Centrecab
Construction*
Year Built*
Top Speed*
In Knots
Motor Type*
In Knots
Sum Insured (incl GST)
Including the hull, motor, equipment and accessories but excludes your trailer.
Watercraft Storage
Storage Method*
In Knots
Trailer Sum Insured (incl GST)
Post Code

Personal Assets Insurance Quote Request Form

Home Insurance

Home Insurance Continued

Have any of these been done in the last 30 years?

Home Insurance Continued

Floor Area

Home Sum Insured

Special Features' Sums Insured

Total Sum Insured

Occupancy

For Tenanted Properties Only

Wrapping up

Policy Excess

Mortgagee details

Contents Insurance

Security

Policy Limits

Policy Excess

Sum Insured

Vehicle Insurance

Drivers

Policy Excess

Optional Covers

Boat & Watercraft Insurance

Watercraft Storage

Declaration Questions

Home & Contents Insurance

Motor Vehicle Insurance

All Insurance