Personal Insurance Form

Your Personal Insurance Information

Insured Details
Contact Details (please specify preferred contact method)
Please specify preferred contact method
How would you like to pay?
House Insurance
What type of home is this:
(Please note: If the home is a Body Corporate or Company Share the policy is to include all units/apartments)
Replacement Value Excluding GST, Including recreational features eg. Tennis courts, permanently fixed swimming pools and/or permanently fixed spa pools including ancillary equipment and/or pumps (s): What is the estimate of the likely cost to rebuild the home and domestic outbuildings in today’s prices? This should include any increased policy limits for retaining walls and Recreational Features listed below, allowance for inflation, demolition, and fees associated with rebuilding.
Please provide a PDF copy of replacement insurance valuation/quantity surveyor report/valuation or online calculator printout.
We recommend you seek independent advice (Insurance Valuer) to calculate your Replacement Value. An online calculator can be found on www.homebuilding.cordell.co.nz
(including all levels of the main house & garage(s))
No of Self-Contained Dwellings:
(No of buildings with self-contained kitchen & bathroom facilities)
(Additional Questionnaire required for house built pre 1945)
Water Supply:
Please list any special features & replacement values of any of the following: (i.e swimming pool, hard wired spa pool, tennis court, gazebo, retaining walls, bridges, culverts, cable cars, permanent fords or dams, wharves, piers, landings, jetties or private utility plant including wind or water mills or diesel generators etc)
If the property is tenanted are you interested in a quote for Malicious Damage by Tenants?
Are you interested in voluntary excess options?
If yes we will provide excess options

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Contents Insurance
Where are your contents located?
Does the property have an alarm system?
Please list specified items valued over $3,000: please give a description (ie: make and model) and value for any; single item of jewellery, watch, collection, camera (film, video, digital or accessory), or bicycle, surfboard, surf ski, kite surfer, paddle board, windsurfer, dinghy, kayak or canoe (including their parts and accessories that are in them or attached to them).
Please list specified items valued over $1,000: please give a description (ie: make and model) and value of all parts & accessories of any watercraft, or motor vehicle, motor cycle, motor scooter, trailer, caravan or aircraft or other aerial device that are not in it or attached to it: any motor vehicle accessory that is attached to your employer's motor vehicle any money, vouchers that can be redeemed for cash, bullions, unset precious stones, credit cards, or stamps not being part of a collection:

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Private Motor Vehicle 1
Cover Required:
Is this vehicle turbo or supercharged?
Main Driver Details
Sex
Licence Type
Second Nominated Driver Details
Sex
Licence Type
Specified Drivers Discount
(Available for Drivers Over 25 only. Main driver + 1 other named driver subject to standard excess. All other drivers would be subject to the standard excess plus an additional excess of $200-$300)
Exclude Drivers Under 25 Years Old?
(only available to drivers over 25 years old)
Do you require Roadside Rescue Cover?
Has this vehicle been modified?

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Private Motor Vehicle 2
Cover Required:
Is this vehicle turbo or supercharged?
Main Driver Details
Sex
Licence Type
Second Nominated Driver Details
Sex
Licence Type
Specified Drivers Discount
(Available for Drivers Over 25 only. Main driver + 1 other named driver subject to standard excess. All other drivers would be subject to the standard excess plus an additional excess of $200-$300)
Exclude Drivers Under 25 Years Old?
(only available to drivers over 25 years old)
Do you require Roadside Rescue Cover?
Has this vehicle been modified?

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Caravan Insurance
Contents permanently kept in caravan

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Boat Insurance
Boat Description:
Hull Type
Construction
Motor Description:
Accessories Description: e.g. Fishing Gear, Diving Gear, Ski Equipment plus values:
(Please advise location and security, including anti-theft devices)
(Please advise location and type of mooring)

If this is your last or only policy section request then please proceed directly to the Declaration / Submit page

Declaration / Submit

Have you or your family members, de facto partner, business partners, directors, trustees and/or beneficial owners, managers or any other person or entity to be covered by the insurance:

(a) In the last 7 years have you:
i. Suffered loss or damage to any property (whether insured or not)?*
ii. Made an insurance claim?*
iii. Been subject to any lawsuit or a legal liability claim or been declared bankrupt?*
(b) Ever had any:
i. Insurance declined, cancelled, avoided, renewal refused, terms imposed or claim declined?*
ii. Criminal convictions (including fraud/jail term etc), acquittals or diversions, or do you have any criminal prosecutions pending, traffic convictions (including speeding, DIC, licence breach etc)?*
Additional Information: Please note any additional information or general remarks you may feel is relevant to this quotation
Please note: It is important you understand your obligation to provide accurate and relevant information as this information is being gathered for quotation purposes only. Quotations may vary depending on a satisfactory proposal being accepted by the insurer.
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