Quote Request Form – Mansions Insurance Brokers

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1. Client Information

Contact Name*

Contact Number*

Email Address*

Insured Name*

Date Of Birth*

DD slash MM slash YYYY

Occupation

Nature of employer’s or your own business

Current insurer*

Renewal date*

DD slash MM slash YYYY

Renewal base premium*

Current excess*

Interested party*

Are you domiciled in Australia?*

Yes

Have you been declared bankrupt in the last 5 years?*

Yes

If yes, please provide details:*

Have you Incurred any loss or damage, (whether insured or not), or had any claims made against you in the last 5 years?*

Yes

If yes, please provide full details (including type of loss, date of loss and amounts paid):*

Had insurance refused, cancelled or had special terms or conditions imposed on an insurance policy in the last 5 years?*

Yes

If yes, please provide full details:*

Been charged with or convicted of a criminal offence in the last 10 years (other than traffic offences)?*

Yes

If yes, please provide full details:*

2. Family CyberSecure

Your (Client’s) email address*

Requires your email address for the purpose of providing access to cyber security tools included within the Family CyberSecure coverage section.

3. Risk Details

Address of property to be insured*

Street Address Suburb State Postcode

Year built*

Is the property Heritage listed?*

Yes

Number of years owned*

Property type*

House

Unit

Other

Other Field*

Property use*

Owner occupied

Tenanted

Occupied by you as a tenant

Unoccupied

Is the property*

Primary residence

Weekday home

Weekend home

Holiday home

Other

Other Field*

If built before 1970, has the property been substantially renovated?*

Yes

If yes, please provide

Year last rewired

Year last replumbed

Year last reroofed

Does the property have a basement?*

Yes

Wall construction

Roof construction

Details if other*

Does the property have a flat roof?*

Yes

Do the external walls or roof contain any of the following materials*

Copper

Zinc

Lead

Asbestos

Is the property on town water?*

Yes

Is the property made available for short term/temporary letting?*

Yes

Is there any pre-existing or suspected pre-existing damage that you are aware of?*

Yes

Is the property structurally sound, watertight and well maintained?*

Yes

Is the property currently occupied?*

Yes

If no, when will it be occupied:*

DD slash MM slash YYYY

Reason for unoccupancy

Other*

Is the property used for any business purposes other than administrative work in a home office?*

Yes

If yes, please provide details*

To your knowledge, has the property or its grounds been affected by flooding, bushfire, wildfire or grassfire?*

Yes

If yes, please provide details*

Is the property undergoing any renovations, alterations or additions or are there any planned in the next 12 months?*

Yes

If yes, please provide details*

Does the home have deadlocks on all external doors?*

Yes

Does the home have key operated window locks on all accessible windows?*

Yes

Is the home protected by an intruder alarm?*

Yes

If monitored, what type?*

Telephone line

Telephone line + GSM

Multipath

Does the home have a strongroom or safe?*

Yes

Make/Model/Cash rating*

Is the safe*

Fixed

Freestanding

Is the safe connected to the alarm*

Yes

Is there any additional security - e.g. electric gates, video entry, CCTV, window grilles, live-in staff, onsite security personnel, etc?*

Yes

If yes, please provide full details*

Is the home protected by smoke detectors?*

Yes

If yes, what type?*

Bells/Local

Monitored

4. Home Cover

Home sum insured including other structures*

Note: Tenanted Properties If you regularly lease out the property on an unfurnished basis, please include the replacement value of carpets, curtains and internal blinds in the home sum insured.

Excess*

$1,000

$2,500

$5,000

Other

If higher excess required, please state*

5. Contents Cover

Contents sum insured*

Note: Additions and alterations (strata properties only) Please provide the replacement value of internal paint work, wallpaper and any fixture or structural improvement pertaining to the unit which the Body Corporate is not required by law to insure.

Excess*

$1,000

$2,500

$5,000

Other

If higher excess required, please state*

6. Private Collections

List of your collections

Title

7. Additional Information

Are there any additional residential locations to be insured?*

Yes

If yes, please complete another Quotation Request Form (pages 2-3 inclusive) for each additional location. Please include any other additional information below.*

About Mansions

Mansions Insurance Brokers is a wholly owned subsidiary of the IMC Insurance Group. Formed in 1994, IMC Insurance Brokers Pty Ltd (AFS Licence Number 229344) is a General Insurance Broker licensed by Australian Securities Investment Commission (ASIC) under the Corporations Act.