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Policy details
Policy period
Form
*
Date Format: MM slash DD slash YYYY
To
*
Date Format: MM slash DD slash YYYY
Who are you insured with
*
AMP
Insured details
Insured name
*
First
Last
Email
*
Phone
Contact name
*
Address
Street Address
Address Line 2
City
State
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
CLAIMS HISTORY
Claims details (Within past 5 years)
Have you during the past 5 years had any insurance declined or any underwriting conditions or excesses imposed?
Yes
No
Have you had any claims in the past 5 years?
*
Yes
No
Policy Cover
Sum Insured
Building(s) at the above situations
*
Loss of rent / temp. accommodation
Common area contents
Legal liability's
*
Voluntary Workers
$200,000
$2,000
Workers compensation
Do you want to cover employees?
Yes
No
Fidelity guarantee
Office bearers liability
Machinery breakdown
Building catastrophe
Extended cover - rent / temp. accommodation
Escalation in cost of temp. accommodation
Storage / evacuation
Government audit costs
Appeal expenses - common property health and safety breach
Legal defence expenses
Lot owners
Questionnaire
Building
Internal Walls (between' units)
*
Please Select
First Choice
Second Choice
Third Choice
External Walls
*
Please Select
First Choice
Second Choice
Third Choice
Floors
*
Please Select
First Choice
Second Choice
Third Choice
Roof
*
Please Select
First Choice
Second Choice
Third Choice
Fences built of
*
Please Select
First Choice
Second Choice
Third Choice
Year built
*
Street Number Type
*
Please Select
First Choice
Second Choice
Third Choice
Street Number
*
Street Name
*
Street Type
*
Please Select
First Choice
Second Choice
Third Choice
No. of unite
*
No. of storeys
*
Heritage listed?
Yes
No
Is the Building maintained to a good standard of repair?
Yes
No
Is the Building occupied?
Yes
No
Please provide the percentage occupied
*
Is any part of the Building used for domestic purposes?
Yes
No
Please provide percentage. used for domestic purposes
*
Do any of the Building's occupants have commercial cooking facilities?
Yes
No
Please select occupancy type(s)
Offices
Retail shops
Industrial
Unit
State Oooupanoy
Note
It is your duty to advise us of any chanegs in the occupations carried on at the risk location.
Are there any air-conditioners or electric motors in excess of Skw?
Yes
No
Do you want cover against breakdown?
Yes
No
Please Indicate the faceless provided by your Strata:
Lifts
Spas
Pools
Tennis Courts
Other
Do you have a strata manager?
Yes
No
Is the insured registered for GST?
Yes
No
To what extent is the insured entitled to claim input tax credits?
*
Please write the Australian Business Number (ABN) here
*
Signature
This electronic signature will be treated the same as if signed personally.
*
This is signature..
Name
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