Claims

Domestic Insurance Application

You need to fully complete all the sections on this form. If any of the information in this proposal is incorrect or deliberately withheld, or if information that you know to be untrue or misleading, this can prejudice a claim or invalidate your policy.

First Name

Surname

Date of birth

First Name (if joint account)

Surname (if joint account)

Date of birth (if joint account)

Cell number

Address (for correspondence)

Contact email

Dwelling

Current insurer

Current expiry

Start date required

Physical address (for insured property)

Occupancy

Lifestyle block or farm? If yes, how many Ha?

Age of construction

Special features

Sqm of dwelling

Sqm of outbuildings

Rebuild value excl. GST

Any special council titles or noted on property? (as per LINZ for eg)

Is any form of business run from home?

Alarms / Security / Fire protection

Is there a bank that requires notice of cover?

We recommend you completed a 'Cordell Calculator' to assist with the rebuild value of your home. If you have an insurance valuation, please provide us with a copy.

Is this for the property above?

Yes

Contents value excluding GST

Specified items to declare. (Item, value)

Private Motor Vehicle

Including trailers, caravans, boats.

Main Driver

Vehicle Details

IMPORTANT

Questionnaire

Have you or any members of your family, or any other person or entity to be covered by these insurances:

In the past 3 years had more than 2 losses or made claims totalling more than $2,500?

Yes

Been aware of any damage from flooding, landslip or earthquake at any address relating to this policy

Yes

Had any insurance declined, cancelled, renewal refused, terms or conditions imposed or claim declined?

Yes

Been engaged in any criminal activity or had any criminal convictions, acquittals or have any criminal prosecutions pending?

Yes

Important notices and declaration

Property Value

Due to recently increased costs of building, we strongly recommend that you complete a ‘Cordell’ rebuild calculation (online) to get an indication of market building values for your property. Please note however that these are a guide only, and you may prefer to ask a builder or obtain a building valuation from a registered valuer

Duty of Disclosure / Declaration

Subject to any rights you have under the Criminal Records (Clean Slate) Act 2004, the information given is in every respect correct and complete and all material information has been disclosed, whether the information is asked for or not.

Material information is information that might influence our decision to insure you and if so on what terms and / or premium. If you have any doubt as to whether a fact is material, then it must be disclosed. The duty to disclose all material information occurs prior to the commencement of cover, if the contract is varied and prior to each renewal. Failure to disclose all material information may result in Insurers avoiding your insurance policy. This means your policy would be deemed never to have existed and any claims would not be payable.

You provide Tasman Insurance Brokers Ltd the right to obtain information from other Insurers/Brokers in order to support your quote.
The information contained in this document shall be the basis of the contract between you and the Insurer, and you are willing to accept cover subject to the Insurers policy terms, conditions, exclusions and any special terms that the Insurer may require.
Further information with regards to the insurances offered will be provided in the quote document supplied to you by Tasman Insurance Brokers

Signature + Date

Contact

299b Queen St Richmond

Karen Botica

FSP 386146

Director / Commercial Broker

0274843238 karen@tibrokers.co.nz

Rachael Gunn

Domestic Broker / Claims /Admin support

FSP 1005798

027 456 1494 rachael@tibrokers.co.nz

Megan Holland

Commercial Broker Support / Broker / Admin support

FSP 600990

021 982 763 rachael@tibrokers.co.nz

Domestic Insurance Application

Dwelling

Contents