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Owner Builder Application Form  
Section 1. Owner Builder Details
Name(s) of all registered owners of the subject property
Trading or Company Name (if applicable) ABN
Name of Owner Builder as per the building permit or
certificate of consent
Builder permit/certificate
of consent number
Are you entitled to claim an input tax credit on the GST
component of the premium applicable to the Policy?
Yes No
If so, how much, 100% or other?
Postal Address
State Postcode
Forwarding Address after the property sale
State Postcode
Telephone Mobile
Telephone - Work Facsimile
Section 2. Address of Property for Sale
Unit Number(s) Lot Number Street Number
Is there more than one dwelling
on the property?
Yes No If yes, the number of units
Street Name
Section 3. Permit Authority/Council
State Postcode
Permit Issue Date
Section 4. Type of Owner-Builder Work
Construction of a Dwelling Dimensions of work
Renovation of a Dwelling
Extension of a Dwelling Commencement of building work
Completion of a Dwelling
Construction of a Garage or Carport Completion of building work
Construction of a Swimming Pool
Non Structural renovation Certificate of occupancy date
Please provide a brief description of theowner-builder work undertaken:
Please advise if the dwelling is situated in a designated termite area?
(If Yes, please provide evidence of termite treatment for compliance with AS3660)
Yes No
Does the owner-builder work include upper level decks or balconies?
(If Yes, please answer the following questions)
Yes No
Is there a fall? Yes No
Is there a dip tray? Yes No
Has the membrane been drilled through to install balustrading? Yes No
Is there a certificate for any waterproofing undertaken from a licensed
waterproofing installer?
(If Yes, please provide evidence of certificate)
Yes No
Section 5. Details of all Contractors/Persons who have carried out work on the Dwelling
(must include any licensed waterproofing membrane installer for any bathrooms/balconies,
geotechnical engineers,electrician, plumber etc.)
Type of work Contractor Name,
Address and Telephone No.
Warranty Insurer Cost of work done
Total Cost of Building Work Sale Price of the Property (as per Contract of Sale)
Section 6. Second Hand Materials
The legislation may vary according to individual state regulation, the owner builder is required to list in the
contract of sale all materials used that are not new.
List all the used (not new) materials (including building products, fixtures, fittings, appliances, paving etc)
installed by the owner builder, their contractors, subcontractors, or employees in relation to the property.
Section 7. Inspector Details
State Postcode
Telephone Mobile Facsimile
Licence Number Qualifications
Section 8. Personal Background Information
Have you at any time ever been refused or declined Builders Warranty Insurance? YesNo
Have you purchased Builders Warranty Insurance as an Owner-builder within the
last five years?
Have you ever held a builders/contractor licence or registration? YesNo
Have you ever had a claim against you or been directed to repair/replace defective
workmanshipas a result of a complaint by a Homeowner?
Is there any relationship between the owner builder and the purchaser? YesNo
Have you ever been declared bankrupt or entered into a deed of
assignment/composition or beensubject to a legal judgement or are currently
involved in any legal proceedings?
If you answered 'yes' to any of the above questions please supply full details
Section 9. Owner-Builder Declaration
I/We acknowledge that on issuance of an individual Owner Builder Warranty Certificate it is the purchaser
and the successors in title to the purchaser who is the insured and not me/us as the applicant/owner builder.

I/We confirm that the information contained in this application is true and correct.

I/We acknowledge that QBE reserves the right to reject any application for insurance.

I/We acknowledge that QBE may seek additional information from me/us as required from time to time.

I/We have read and understood the Privacy Statement and Duty of Disclosure sections outlined in this

I/We will reimburse QBE any monies that QBE pays to the Insured in settlement of a claim under the policy if

I/We fail to comply with any laws or regulations relating to the building work and/or for used second hand
materials which were not declared in this form or to the prescribed building inspector and if not so noted
in the prescribed building inspectors report or in the contract of sale and/or not carried out the works in
a proper and workmanlike manner.

I/We authorise QBE to give to, or obtain from, other insurers or insurance reference bureaus, credit reporting
agencies and government departments any information about this insurance including this completed
application and my insurance claims history.

Declared by all Applicants/Owners of the property:
Print name Date

Declared by all Applicants/Owners of the property:
Print name Date

Companies Trusts & Partnerships:
For and on behalf of Date
Position held

Companies Trusts & Partnerships:
For and on behalf of Date
Position held
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