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| Your details |
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| Your name : |
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| Postal Address : |
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| State : |
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| Postcode : |
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| Your Email Address : |
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| Your Phone Number : |
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| Your Fax Number : |
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| Insured Property Details |
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| Owners Corporation Plan No. : |
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| Name of Insured : |
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| Address to be Insured : |
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| Suburb : |
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| State : |
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| Postcode : |
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| Current Insurer : |
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| Excess ($) : |
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| Due date : |
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| Year Built : |
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| If built before 1950, has the house been rewired / replumbed in the last 40 years? : |
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| No. of units : |
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| Storeys : |
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| Walls : |
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| Roof : |
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| Floors : |
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| Fire protection : |
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Hydrants |
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Hose Reels |
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Sprinklers |
| No. of lifts : |
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| No. of pool / spas : |
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| No. Gyms : |
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| Professional Managed? : |
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| Sum Insured |
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| Building ($) : |
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| Common Contents ($) : |
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| Public Liability : |
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| Voluntary Workers / Personal Accident ($) : |
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| Office Bearer Liability ($) : |
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| Fidelity Guarantee ($) : |
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| Machinery Breakdown ($) : |
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| Last 5 years claims history : |
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| You may wish to upload previous claim history via an attachment :
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| Additional Comments : |
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