Home Insurance Form
Your Details
Full name: (incl Title)
*
Date of birth:
Contact telephone number:
*
Email address:
*
Home Details
Home address:
*
Postcode:
*
Building type:
Please select
Single storey house
Multi storey house
Town house
Unit - ground level
Unit above ground level
Security unit
Brick veneer
Walls:
Please select
Brick
Brick veneer
Fibro
Weatherboard
Wood
Year built:
Occupancy
Owner Occupied
Rental
Unoccupied
Holiday Home
Year last rewired:
Insurance Requirements
Building Sum Insured:
Contents Sum Insured:
Valuables Sum Insured:
Unspecified Valuables Sum Insured:
Domestic Workers Compensation:
Yes
No
(If yes - number of employees)
Security
Please tick the security questions that apply to you:
Double keyed deadlocks on all external doors
Keyed window locks on all windows
Window grilles / bars on all windows
24 hour security person / concierge
Security card / security pad access to floor
Unit at least 2 floors above ground
Alarm - securitel
Alarm - monitored
Alarm - local
Fixed safe
Neighbourhood watch area
Please provide full details of any claims made and/or losses suffered under a similar Home Insurance policy during the past 5 years (whether or not a claim was made):
*
If none, please state
Please use this box to provide any further information that may be relevant to your Home Insurance policy:
Current Home Insurance provider:
*
If none, please state
Current Home Insurance premium:
*
If none, please state
Renewal date of existing insurance / date cover to start (as applicable):
*
NB: Cover is not in force until agreed upon by the company
Contacting You
Are you an existing Dental Essentials Insurance customer?
*
yes
no
Preferred contact method:
*
Please select
Telephone
Email
Letter
Preferred contact time:
Please select
No preference
08:00-10:00
10:00-12:00
12:00-14:00
14:00-16:00
16:00-18:00
How did you hear about us?
*
Please select
Referred by friend
Referred by another business
Referred by another website
Search engine
Advertising
Dental Essentials is a trading name of Bourchier Nominees Pty Ltd. We would like to contact you from time to time about products and services (or with news, offers and promotions) that we feel may be of interest to you. By providing us with your contact details, you consent to being contacted by these methods for these purposes.
Please tick the box if you prefer to
not
receive marketing communications from us by post or telephone.
Please tick the box if you prefer to
not
receive marketing communications from us by email, text messaging or other electronic means.