Insurance House Group

Name of Insured:*

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Address:*

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Contact Person:*

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Phone:*

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Mobile Phone:

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Email:*

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DOB:* (dd/mm/yyyy)

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Retired:* -- Please select -- Yes No

Type of enquiry: -- Please select -- Accidental Damage - Home and Contents Defined Events - Home and Contents Landlords Strata

If you are a Landlord - do you require?: Rent default
Theft by Tenants
Malicious damage by tenants

Insurers Property Address:

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Sums Insured ($):

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Building ($):

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Contents ($):

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Valuables ($):

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Year of Construction:

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Building Type: -- Please select -- House Unit Other

Occupied by: -- Please select -- Owner Tenant Holiday Home Vacant

Construction: -- Please select -- Brick/Steel Other

Security: Back to Base Alarm
Local Alarm
Window Bars
Deadlocks to Doors
Security intercom

Have there been any claims for home and/or contents in the past 5 years: -- Please select -- Yes No

How did you hear about us?: -- Please select -- Existing client Bicycle Victoria Orica AAMT Symbion Health Family or Friend Other

Message:

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