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Home & Contents Application Form  
   
THE APPLICANT/S
Name(s) of Insured in full, if insufficient space or if policy in name of company or other entity please attach detailas
Date of Birth Are you retired?
Tax Status
Registered Business? Yes No ABN Taxable
Postal Address for Notices  
Contact Numbers
Phone No.(Private) Phone No.(Business)
Fax No. Email
Motgagee's Name
Address
Postcode
Contact Numbers
Phone No.(Private) Phone No.(Business)
Fax No. Email
Period of Insurance
From To at 4 p.m
INFORMATION ABOUT THE HOME AND CONTENTS
Site of Home
(Tick if same as postal)
Postcode
Please tick the appropriate box.
1) How is the home occupied    
By you as owner By tenant (your home) By you as tenant/renting (not sharing)
Holiday home Farm owner occupied Farm not owner occupied
Vacant home Other give details
(unoccupied more than 60 days) Tick here is you require cover for malicious damage by tenants for an additional premium
2) Type of home:
Freestanding House Home Unit/Flat Townhouse/Terrace/Villa Other
Construction Walls
a) Walls Brick Fibro Wood Other
b) Roof Tile Iron Colourbond Other
Size of home sq m or squares Year of construction
4) Is the home connected to town water? Yes No 4 (a) Is the site larger than 2 hectares? Yes No
5) Is your home heritage listed? Yes No If "Yes," give details
6) Condition of home:
Good Average Needs Maintenance & or Repairs -give details
7) Has the home been - Rewired? No Yes - If "Yes", year
  - Replumbed No Yes - If "Yes", year
8) Does the home have any of the following protection?
Deadlocks on all external doors Yes No Security intercom Yes No
Keyed locks on all accessible windows Yes No Fixed safe Yes No
Bars on all accessible lourve windows Yes No Neighbourhood watch area Yes No
Professionally installed local alarm Yes No Smoke detectors Yes No
Professionally installed monitored alarm Yes No    
If you live in a flat/unit that is at least 2 floors from the ground at its lowest point, does it have:
24 hour concierge/security person? Yes No Security access to your floor by card or P.I.N? Yes No
9) Have you or anyone living permanently living with you: Yes No
a) Been refused insurance; been declined renewal of insurance; been quoted an increased premium; or had any special terms or conditions imposed e.g. excess imposed by abc insurance co in 2003 following a theft claim?  
If "Yes", give details  
b) been charged or convicted during the last 5 years or arson or any offence involving accual or threatended damage to property; any criminal act; fraud; theft; drugs; or dishonesty of any kind e.g. (name) fined $500 in 2003 for shop stealing? Yes No
If "Yes", give details  
c) suffered any loss during the past five years from any events against which you wish to insure e.g. storm claim approximately $3,500 in 2003? Yes No
If "Yes", give details  
10) are there any exceptional circumstances you know about which are relevant to our decision to insure you and on what terms? Yes No
If "Yes", give details  
Please state the name of your previous home and contents Insurer     Expiry date of previous Insurance
How much did you want to insurer for?
  Sum Insured Excess Premium Amount Payable
Home  
Unspecified Contents
There are limits to the amount we pay on certain items. These items are limit set out in the policy under how we will pay. You may obtain higher limits by specifying any of these items below. We pay up to the amounts specified.

Specified Contents e.g. (under the insured events policy) antiques or works of art over $7,500, jewellery, watches over $1,500 or collections of any kind over $5,000. Please list here any contents items you wish to specify and provide as much identification as possible e.g. serial numbers, valuations, receipts.
     
     
     
     
     
     
     
Sum Total Specified Contents Excess Premium Amount Payable
Total Contents Sub Insured (unspecified plus specified)
(If unsufficient space please attach details.)
You should keep your policy in a safe and convinient place, and also keep receipts or other evidents of ownership and value of items you have specified here and other items of significant value.
VALUABLES
A) INSURED EVENTS POLICIES
you may elect to insure unspecified personal property against accidental loss or damage anywhere in Australia or New Zealand and for up to 35 days, anywhere in the world. If you choose this option, please nominate a sum insured in the unspecified valuables box at the foot of this section (up to $6,000). The maximum we will pay for any item is 25% of the sum insured. This cover attracts an extra premium.
Additional items may be individually specified below.
1. UNSPECIFIED VALUABLES
Please keep receipts or other evidence of ownership and value of these items.
We will insure as unspecified valuables But Not
Unspecified personal property specifically designed to be worn or carried on your person which means:
  • Jewellery
  • Gold or Silver objects
  • Watches
  • Sporting equipment except while in use or play
  • Photographic equipment including video equipment
  • Musical equipment
  • Battery operated sound equipment
  • Binoculars
  • Clothing
  • Other personal belongings specifically designed to be worn or carried on the person
  • Luggage
  • Camping equipment, back packs and sleeping bags
  • Wheel chairs, crutches and walking sticks
  • Vehicles
  • Aircrafts, aerial devices
  • Watercraft
  • Equipment normally associated with the above 3 items
  • Cash or negotiable securities
  • Musical instruments or photographic and video equipment including associated equipment used for professional purpose or reward
  • Bicycles (these must be listed as a Specific Item)
Total Unspecified Valuables
2. SPECIFIED VALUEABLES - please list specific items you wish to insure. This section attracts an aditional premium
Please provide as much identification as possible, e.g. serial numbers and attach a valuation for any item in excess of $1,500.
Total Specified Valuables
B. ACCIDENTIAL DAMAGE POLICIES
Additional Benifit (1) Temporary Removal automatically isurers your contents anywhere in Australia, New Zealand and for up to 90 days, anywhere in the world.

We will pay a maximum of $1,500 per item and $7,500 in total for items of:
  • Jewellery, gold or silver articles, furs, watches
  • Collections of any kind
  • Mobile phones, portable electronics equipment
Bicycles are insured for a maximum of $2,000, unless specified
Additional items may be specified below.
SPECIFIED VALUABLES - please list specific items you wish to insure. This section attracts an additional premium.
Please privide as much identification as possible, e.g. serial numbers and attach a valuation for any item in excess of $1,750
Total Specified Valuables
Total Valuables
Premium
Excess
Amount Payable
LEGAL LIABILITY
LEGAL LIABILITY  
$20,000,000 Amount Payable
WORKERS' COMPENSATION
NB: Not applicable for Queensland, Victoria, and South Australia

If you employ a domestic worker, on a casual basis or otherwise, you may be required by law to provide that person with workers' compensation insurance. If you fail to do so, and your employee is injured in the sourse of their employment by you, you may be liable to compensate them.

You may insure your liability according to the legislation in your state, up to the amount required by your state's legislation.
Do you require this cover? No Yes If "Yes", how many people do you employ? Premium
Privacy
Privacy legislation regulates the way private sector organisations can collect, use, keep secure and disclose personal information.
QBE has developed a privacy policy which explains what sort of personal information we hold about you and what we do with it. You can obtain a copy of the QBE Privacy information brochure from any QBE Commercial office or at qbecommercial.com
DUTY OF DISCLOSURE
What you must tell us
When answering our questions, you must be honest and you have a duty under law to tell us anything known to you, and which a reasonable person in the circumstances would include in answer to the questoin. We will use the answers on deciding whether to insure you, and on what terms.
Who needs to tell us
It is important that you understand you are answering our questions in this way for yourself and anyone else whom you want to be converted to the policy.
NON-DISCLOSURE
If you do not tell us
If you do not answer our questions in this way, we may reduce or refuse to pay a claim or cancel the policy. If you answer our questions fraudulently, we may refuse to pay a claim and treat the policy as never having worked.
Declaration
I/We declare that:
  1. I have received a copy of the Products Disclosure Statement (PDS) and the Policy Terms and Conditions and agree to be bound by the terms and conditions contained in it.
  2. The Duty of Disclosure and inadequate space to answer, notices set out above has been read and understood by me/us.
  3. All answers and statements made in this application are true and accurate in every respect and no information has been withheld which is likely to affect your decision about accepting this insurance.
  4. I acknowledge you have the right to decline any application.
  5. I authorise QBE Insurance (Australia) Limited ABN 78 003 191 to give to, or obtain from , other insurers or insurance reference bureaus, or credit reporting agencies any information about this insurance or any other insurance of mine including this completed application and my insurance claims history and my credit history.
  
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