Step 1 of 8 - Your Name 12% Can I start with your name?First Name(Required)Last Name(Required) Nice to meet you! What type of cover are you looking for?Cover Type(Required) Thanks for your selection! Where do you currently live?Address(Required) Street Address Great! What are your building and contents sum insured?Great! What is your building sum insured?Building Sum insuredGreat! What is your contents sum insured?Contents Sum insuredDo you require cover for any portable items outside the insured address?(Required) Yes No How much do you need?Do you require additional cover for valuable items?(Required) Yes No How much do you need? Can you tell us about your home?Building type Are you currently insured?(Required) Yes No Who is the current insurerIs business conducted from home?(Required) Yes No This field is hidden when viewing the formSection BreakIf yes, Please provide details of the business occupationWhat is the annual turnover for the business?Is the property zoned for residential?(Required)(normal size house block) Yes No Is this your primary residence?(Required) Yes No Does the business take up more than 50% of the property?(Required) Yes No Do you currently have business insurance?(Required) Yes No If Yes, what is it for?eg liabilityWhat is the name of the business?Do you have clients who come onto the property?(if so, approx. how many and how often)Do you have a separate building on the property for the business?(Required) Yes No Do you have heat related equipment for the business?(Required)(eg. Ovens, torches,etc) Yes No This field is hidden when viewing the formHeat related questionsWhat Fire Protection do you have in place where the Kiln / commercial Oven is KeptFire Extinguisher(Required) Yes No Fire Blankets(Required) Yes No Smoke Detectors(Required) Yes No Is the area where the Kiln/ commercial over kept free from combustible materials(Required) Yes No If No please provide detailsPlease list itemsItem NameDescriptionValue This field is hidden when viewing the formSection BreakDo you have fire protection in the business area?(eg fire extinguisher, fire blanket, etc)Is any heat related equipment left on unattended?(Required) Yes No If Yes, please explainDoes the contents sum insured noted, include the business contents?(Required) Yes No If No, please state the sums insured for your regular contents and your business contentsDo you have solar panels on your roof?(Required) Yes No Are you connected to town water?(Required) Yes No Are you close to bushland?(Required) Yes No If Yes, please explain approx. how far awayDo you have any jewellery or art works/oriental rugs that need to be specified?(Required) Yes No Please list itemsItem NameDescriptionValue Do you have any Security?(Required) Yes No Please provide Details of security(eg: Deadlocks, Monitored Alarms and Smoke detectors etc.)Date of Birth(Required) DD slash MM slash YYYY This field is hidden when viewing the formSection BreakOccupancy typeSelect one...Owner OccupiedRent/LeaseHoliday HomeNumber of BedroomsNumber of BathroomsIs there any Finance on the Home Yes No If Yes Please advise Finance CompanyYear the building was constructed?What is the wall constructed of?Select one...Double BrickBrick VennerAluminiumFibro/Asbestoshardiplank/HardiflexConcreteSteelStoneVinyl CladdingWeatherboard/WoodSandwich FoamMud BrickStrawOtherWhat is the roof constructed of?Select one...TileTin/ Steel / ColourbondIron (Corrugated)AluminiumFibro/AsbestosConcreteSlateThatchTimberQuality of the buildingSelect one...Standard qualityAbove AverageTop of the rangeHow many storeys in the building?(Required)Select one...123 or moreSplit levels are considered separate levels.Will the property ever be unoccupied for more than 100 days?(Required) Yes No Is the property poorly maintained or in poor condition?(Required) Yes No Is the property under construction/renovation?(Required) Yes No Is the property heritage listed?(Required) Yes No Can you tell us about your home security?Type of security on external doors(Required) What type of window security do you have?(Required) Type of alarm(Required) Lets talk about your claims history for the past 3 yearsNumber of claims in last three years(Required)Select one...0123456789+When did you make your most recent claim?Have you been declined insurance?(Required) Yes No Have you had a claim declined?(Required) Yes No Have you had any criminal convictions for fraud or arson?(Required) Yes No Almost done! May I grab a few quick details?When would you like the policy to be effective from? DD slash MM slash YYYY Add this to an existing package?(Required) Yes No Payment Type(Required) Annual Instalments Email address(Required) Phone(Required)Mobile(Required)Date of birth of the oldest insured(Required) DD slash MM slash YYYY Informed ConsentWe are required by law to obtain your informed consent to earn commission prior to arranging your policies. Insurer - Australian Approved Type of Insurance - Home and Contents Insurance Item - As per application form Range of Commission - 1% to 20% These commissions will be received Monthly or annually, depending on your payment preference for this policy. The services that we will provide are outlined in our terms of engagement document. This consent will apply to future renewals of these policies and is irrevocable. The parties may vary the consent by agreement. We will contact you to request a modification of your consent regarding the renewal or alteration of an insurance product if any of the following situations change: the product issuer changes; there is an additional monetary benefit as a result of the variation/endorsement (that is a benefit in addition to the commission payable at the rate and frequency as set out in the existing informed consent); the rate of the monetary benefit increases; or the frequency of any monetary benefit changes. I have read and understood that City Rural Insurance Brokers Pty Ltd earns commission as outlined in the above correspondence and confirm my consent to them receiving commission(Required) I AcceptCAPTCHAThis field is hidden when viewing the formSection BreakCommentsThis field is for validation purposes and should be left unchanged.
