Steel Pacific Insurance Brokers

Insured's General Information

Name of Insured(s):

D.O.B:

Company Name:

Situation of risk:

Phone (business):

Fax:

Mobile phone:

Email:

Are you willing to accept all correspondence relating to your insurance via email?

Yes

No

Policy Type:

Landlords

Home Buildings

Home & Contents

Contents Only

Type of Insurance

Cover Type:

Accidental Damage

Defined Events Only

Building Sum Insured $:

Contents Sum Insured $:

Specified Contents:

1)

$

2)

$

3)

$

Specified Valuables Cover $:

Year Built:

If over 50 years; rewired?

Yes

No

Construction

Walls:

Brick

Veneer

Timber

Concrete

Block

Other:

Floor:

Concrete

Timber

Roof:

Colourbond

Tile

Iron

Other:

Built on:

Concrete (no space between ground & floor)

Stumps/Foundations (clear space between ground & floor)

Queenslander/poles elevated off ground

Queenslander/poles elevated off ground up to 1m

Queenslander/poles elevated off ground up to 2m

Queenslander/poles elevated off ground over 2m

Slope of Land:

Flat

Gentle

Moderate

Severe

How many storeys?

How many units?

Number of Bedrooms (incl. studies):

Number of Bathrooms:

Swimming Pool / Spa?

Yes

No

If 'Yes', please specify:

Lifts / Hoists

Yes

No

If 'Yes', please specify:

What is the length of fencing around the property?

Less than 1000m

Greater than 1000m

The property in good condition?

Yes

No

Security & Fire Protection

Smoke Detectors

Yes

No

Alarm Local Base

Yes

No

Security Cameras

Yes

No

If Yes, details:

Doors:

Standard

Deadlocks

Double Deadlocks

Windows:

Standard

Keyed Locks

Grills & Screens

Cyclone Protection

Window Protection:

None

All windows have plywood covering

All windows have cyclone shutters

Roller Doors:

No roller door(s)

Have roller door(s) but not all braced

Installed aftermarket roller door bracing

New roller door installed after 2012

Roof Improvements:

No additional upgrades

Complete roof replacement with Form 16 compliance with relevant building regulations

Original roof cladding has been replaced and sarking installed

Ridge caps have been upgraded

Sheds and Outhouses:

No sheds/outhouses

Sheds/outhouses but no cyclone protection

Sheds/outhouses cyclone rated and anchored to concrete slab

Sheds/outhouses cyclone rates NOT anchored to concrete slab

Sheds/outhouses cyclone kit installed and anchored to concrete slab

Sheds/outhouses cyclone kit installed NOT anchored to concrete slab

Please tell us of any other improvement measures you have taken:

Flood Protection

Barrier Protection:

None

Permanent barriers installed

Automatic barriers installed

Flood Resistant External Doors and Windows:

Standard doors & windows

Flood resistant external doors & windows

Anti-Backflow Valves:

None

Anti-backflow valves installed

Bushfire Protection

Bushfire Gutter Guards:

None

Gutter guards installed

Bushfire Sprinkler System:

None

Sprinkler System installed

Occupancy

Occupancy Type:

Owner Occupied

Tenanted

Holiday Home

Is the property currently unoccupied or expected to be unoccupied for more than 90 continuous days during the period of cover?

Yes

No

Leasing

Is your property managed by a professional property agent?

Yes

No

Is there a lease agreement in place?

Yes

No

Mortgagee

Mortgagee:

Flood required?

Yes

No

Flood Prone Area?

Yes

No

Any Flood claims?

Yes

No

Flood / Inundation

Has the Land been subject to Flood or Inundation by water?

Yes

No

Storm Surge required?

Yes

No

Storm Surge Prone Area?

Yes

No

Any Surge claims?

Yes

No

Business from Home

Do you own or operate any business from home?

Yes

No

If 'Yes' what is the occupation:

If 'Yes', a separate Public Liability Policy is required. Complete the Liability Section of the Commercial Business Needs Analysis

Claims in last five (5) years

Date	Payout	Description

Previous Insurer:

Policy Number:

How many years have you held Home/Contents Insurance for?

How many years have you been claims free?

Expiry Date:

Excess:

Rent Default

Annual / Weekly Rental Income $

Tenant Damage:

Yes

No

Tenant Rent Default:

Yes

No

Loss of Rent Cover required?

Yes

No

Land Size & Additional Features

Is Land Size Greater > than 2 Hectares?

Yes

No

If 'Yes', size:

Are there Jetties, Pontoons, Marinas etc?

Yes

No

If 'Yes', size:

Duty of Disclosure

In the past 5 years, have you or any person to be insured under this policy, been convicted of a criminal offence?

Yes

No

Have you, or any person to be insured under this policy, ever been declared bankrupt, in liquidation or entered into insolvency?

Yes

No

Has an insurance company ever declined to accept insurance from you, cancelled a policy other than by your request or declined to renew a policy held by you?

Yes

No

Insurance Needs

Do you have any other insurance needs not listed above?

Yes

No

Please specify:

Outcomes & Comments

Outcomes & Comments:

Account Manager:

Details Taken By:

Today's Date:

WEF Date:

Membership Details

You may be entitled to a discount from participating underwriters

Does any Insured hold a Seniors Card?

Yes

No

Club Membership (Card colour for RACQ, NRMA etc.)

Blue

Bronze

Silver

Gold

Gold 50

Broker Only Section

Most Important Features

Rank which is most important to the client (in the order of importance, 1 being most important).

Price of the Insurance:

Lower Excess:

The Insurer's Claim Paying Record / Service:

The Insurer's Credit Rating / Financial Strength:

Australian Insurer:

Other:

Insert details of Other:

Best Interests Assessment

Will the client be better off with a new policy?

Yes

No

If 'Yes', detail why the client is better off:

Home/Landlords Fact Finder

Sunshine Coast

North Queensland

Central Queensland

Additional Information

Insured's General Information

Type of Insurance

Construction

Security & Fire Protection

Cyclone Protection

Flood Protection

Bushfire Protection

Occupancy

Leasing

Mortgagee

Flood / Inundation

Business from Home

Claims in last five (5) years

Rent Default

Land Size & Additional Features

Duty of Disclosure

Insurance Needs

Outcomes & Comments

Membership Details

Broker Only Section