(08) 6147 3200
ultra@uis.com.au
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Quote Form Home and Contents
Contacts
Situation of Risk
Insurance Options
Insurance History
Additional Information
Contacts
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Next
Name
Email
Phone number/mobile
Mailing address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Birth date
Relationship to property
Please select
Owner
Owner and Insured
Partner and Insured
Insured
Partner
Family Member
Property Manager
Third-party Advisor
Other
Describe relationship to property
Are additional contacts required?
Yes
No
Additional Contacts
Additional Contacts #1
Name
Email
Phone number/mobile
Birth date
Relationship to property
Please select
Owner
Owner and Insured
Partner and Insured
Insured
Partner
Family Member
Property Manager
Third-party Advisor
Other
Describe relationship to property
+ Additional Contacts
Situation of Risk
Previous
Next
Is the property address the same as the primary contact person's mailing address?
Yes
No
Home address
(Cannot be a PO Box)
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Year of construction
Building type
Please select
Freestanding House
Townhouse
Terrace
Apartment / Flat / Unit
Semidetached
Duplex
Triplex
Quadruplex
Granny Flat
Nursing Home Unit
Retirement Village Unit
Other
This property is or subject to...
a) Part of a strata title
Yes
No
Please provide details
b) Used for business purposes other than a home office or surgery
Yes
No
Please provide details
c) Under construction, reconstruction, or renovation
Yes
No
Please provide details
d) Poorly maintained, in disrepair, or in bad condition
Yes
No
Please provide details
e) Currently unoccupied, or expected to be unoccupied for more than 90 continuous days
Yes
No
Please provide details
f) Under any heritage listing or national trust listing order
Yes
No
Please provide details
g) Used as a hostel, bed and breakfast, or guesthouse
Yes
No
Please provide details
h) Used for community housing or public housing
Yes
No
Please provide details
i) Fitted with a swimming pool, built-in outdoor spa, or lift
Yes
No
Please provide details
j) Rewiring at any point
Yes
No
Year rewired
k) Replumbing at any point
Yes
No
Year replumbed
l) Connected to the mains water supply
Yes
No
What are the premises' water sources?
Water Tank(s)
Dam
Windmill
Bore Pump
Other
Describe water sources
How is the home occupied?
Please select
Owner Occupier - Primary Residence
Owner Occupier - Holiday Home
Tenant
Landlord
Boarder
Owner - Unoccupied House
Other
Describe how home is occupied
Number of storeys
What is the property built on?
Please select
Concrete Slab
Stumps
Poles
Other
Describe the foundations
What are the floors constructed from?
Please select
Concrete
Concrete and Wood
Wood
Other
Describe the flooring
How are the walls constructed?
Please select
Double Brick
Brick Veneer
Timber / Weatherboard
Concrete
Hardiplank / Hardiflex
Corrugated Iron
Steel
Fibro
Asbestos
Stone / Sandstone
Mudbrick
Vinyl Cladding
Expanded Polystyrene (EPS) / Sandwich Panels
Other
Describe the wall construction
How is the roof constructed?
Please select
Iron / Steel
Colorbond
Concrete
Tiles
Fibro
Wood
Asbestos
Other
Describe the roof construction
External doors - select the security applicable
Double Cylinder Deadlocks
Single Cylinder Deadlocks
Key Card Access
Roller Shutters
None
Other
Describe external door security systems
External windows - select the security applicable
Keyed Window Locks
Security Bars / Screens
Roller Shutters
None
Other
Describe window security
Alarm/CCTV system - select the security applicable
Local Alarm
Monitored to Insured's Mobile
Monitored to Monitoring Company
Internal Cameras
External Cameras
None
Insurance Options
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Next
Which type of policy do you require?
Please select
Accidental Damage
Defined / Listed Events
Building sum insured (replacement value)
$
Unspecified contents sum insured (replacement value)
$
Specified contents
Description
Sum insured
$
+/-
Specified valuables - Away from home
Description
Sum insured
$
+/-
Is there an interested party?
Yes
No
Interested party name
Interested party type
Please select
Bank / Financial Institution
Landlord
Lessor
Other
Describe interested party
Insurance History
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Next
In the last 5 years have you
i. had insurance refused, cancelled, declined, or special terms imposed?
Yes
No
ii. been declared bankrupt, placed in liquidation, receivership, or voluntary administration?
Yes
No
iii. been convicted of or had any fines imposed for any crime involving drugs, dishonestly, arson, theft, fraud, or violence against any person or property?
Yes
No
If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.
Claims History
In the last five years has the owner suffered any loss or claims made against you that has not already been declared?
Yes
No
List any claims from the last 5 years
Insurer
Claim date
Type of claim
Amount paid
Finalized
Description
Please select
Malicious Damage
Water Discharge/Burst Pipe
Glass External/Internal
Impact/Vehicle
Theft/Burglary
Liability – Property
Liability – Personal Injury
Electrical/Fusion/Pumps
Other
Storm Damage – Building/Contents
Fire
Accidental Damage
Storm Other
Malicious Damage
Hail Damage
Storm Damage - Fence
$
Please select
Finalized
Not Finalized
Additional Information
Previous
Submit
Please provide any additional information relevant to your risk, or additional covers you may require
Policy effective date
Policy Expiry Date
Would you like to pay monthly?
Yes
No
Who is your current insurer?
What is your current premium?
$
What is your current excess?
$
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