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Mobile Number*
Home Number
Work Number
PROPERTY TO INSURE
Address of Premises being insured *
Start Date
End Date
Please choose correct date range. Dates cannot range for more than 366 days
FOR THE PURPOSE OF THIS INSURANCE THE SUMS INSURED MUST REPRESENT THE REPLACEMENT COSTS OF THE PROPERTY
Building ("A" Class)
$
Retaining Walls
Swimming Pool
General Contents
Electronic Equipment
Jewellery (All Risk World Wide)
Computer Desktop (Premises)
Laptop (All Risk World Wide)
Camera (All Risk World Wide)
Cellphone (All Risk World Wide)
$ 0
Construction of Building (Construction Materials):
EXTERNAL WALLS
ROOF
FLOORS
Number of Stories 1 (ONE)2 (TWO)3 (THREE)
Is/Are the building(s) in a good state of repair and will they be kept so? YESNO
Has any Insurer, in respect of the Risks to be Insured:
A) Declined to insure you? YESNO
B) Cancelled or Refused to Renew? YESNO
C) Increased your premium at Renewal? YESNO
The building is a : ApartmentFlatTownhousePrivate House
Premises occupied by: InsuredTenants
How many days (consecutive) will the premises be left without any inhabitant in any ONE year:
Will the premises be used for any profession, trade &/OR business: YESNO
If YES, give details:
Mortgagee Name
Mortgagee Address
Have you had Claims/Losses in respect of the risks to be insured in the past five (5) years?: YESNO
Is the cover against the peril of collapse due to subsidence and landslip required? YESNO
Disclaimer
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