General Insurance Referral Form

Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone Number*
(including country code)
Insurance Advice (Domestic)
Has the client been convicted of any criminal offences?*
- Yes
- No
What type of insurance coverage do you need?
- Home Buildings
- Home Contents
- Automobile
Date of Commencement
DD slash MM slash YYYY
Have you made a claim in the past 5 years? If so detail
Coverage typs
- Flood coverage
- Is there any private flood mitigation measures in place
Building address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Land Size (Square meters)
Interested Financiers?
Building Value
Contents Value
List specific content with a valuer over $5,000
Type of Dwelling
Number of Stories
Strata Title / Community Title
Occupancy
Year of Construction
Construction
- Is the building currently being renovated or subject to demolition?
- If over 50 years, has the property been rewired?
- If over 50 years, has the property been re-plumbed?
- Is the building in good repair?
- Is the property heritage listed?
- Is any part of the building used for commercial purposes?
- Is there a list in the building
- Is there a pool and/or spa?
- Is there a playground?
- Is any proportion of the building or contents below ground level (eg Basement)?
Floor
Walls
Roof
Security
- Deadlocks on External Doors
- Key Operated Locks on Windows
- Bars / Grills on accessible Windows
- Roller Shutters on Windows
- Live in Caretaker / Manager
- Surveillance System
- Safe
Alarm
Additional Questions
- Loss of Rent
- Malicious Damage Theft by Tennant
- Short Term Rental
- Property Manager
Weekly Rental ($)
What is important to you?
- Stolen Money or Credit Cards
- Temporary Accommodation
- Claims Paying Service
- 24 Hour / 7 day service
- Cost of Premium
- Are you interested in paying a higher Premium in order to lower your excess
- Are you interested in paying a higher excess in order to lower your premiums
- Would you like to pay monthly

General Insurance Referral

Insurance Advice (Domestic)

[email protected]03 9209 9000

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