Domestic Property Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Policy Due Date
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Interested Party
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Property Details
Insured Property Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Building Type
Please Select
House
Townhouse
Unit/Flat
Year Built
Does the property have an E-Charger installed? If so, please specify
Wall Construction
Please Select
Brick Veneer
Double Brick
Weatherboard
Cladding
Other
If other, please detail below:
Roof Construction
Floor Construction
No. of Bedrooms
No. of Bathrooms
Occupancy
Please Select
Owner Occupied
Tenanted
Landlords
Connected to Town Water
Please Select
Yes
No
Security
Number of Floors
Please Select
Single Story
Double Story
Triple Story
Elevated
Split Level
Is the client retired?
Please Select
Yes
No
Size of Property (if over 5 acres)
Flood Cover?
Please Select
Yes
No
Type of Cover
Please Select
Insured Events
Accidental Damage
Landlords
Notes
Sums Insured
Building Sum Insured
Contents Sum Insured
Loss of Rent
Rent Default
Please Select
Yes
No
N/A
Valuables
Valuables - Item Description
Sum Insured
Specified Contents
Sum Insured
Claims History
For last 5 years
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
2 digit day, 2 digit month, 4 digit year
Date
Details of Claim #3
Claim #4 etc.
Disclosure Questions
Business Use
Rows
Yes or No
Provide Details
Will any part of the property be used for farming (including hobby farming))?
Yes
No
Is a business ran from your home?
Yes
No
Notes
Rows
Yes or No
Is the property used for short term accommodation (i.e. Airbnb)?
Yes
No
Is the building classified as a Historical Building or listed by the National Trust?
Yes
No
Has the land where the building or contents situated been flooded or inundated by water more than once in the last 10 years?
Yes
No
Is the home located within 250 metres of any named natural water course?
Yes
No
Has the property experienced an earthquake in the last 3 years or is it currently threatened by fire, hail or a named cyclone?
Yes
No
Will the building be unoccupied for more than 60 consecutive days? (If yes, note unoccupancy period below i.e. start date and end date & whether anyone residing in the home during unoccupancy)?
Yes
No
Will any part of the property be used for farming (including hobby farming) or used for business?
Yes
No
Do you share the building with anyone who is not a member of your family?
Yes
No
Have you or anyone residing at these premises ever had a claim refused or a policy cancelled, declined or special conditions imposed?
Yes
No
Is the land size of this property greater than 2 hectares (5 acres)?
Yes
No
Have you or anyone residing at the premises been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property in the last 5 years?
Yes
No
Have you or anyone residing at the premises been declared bankrupt and not discharged within the last 12 months?
Yes
No
Is the property well maintained, structurally sound and secured against wind & rain?
Yes
No
Is the building undergoing renovations, under construction or to be demolished?
Yes
No
Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about and that you know or should know may affect the Insurer’s decision to accept the insurance?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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