Farm Insurance Quote Form

Farm Insurance Quote Form
Insured Name*
Contact name*
Email*
Retype email*
Risk Address of the Property to be insured *
If more than one address please add other addresses below
Risk Address of the Property to be insured
Only Complete if more than one address
Suburb*
Post Code*
State*
Birth Date Of Oldest Insured*

DayMonthYear
Prefer Pay Monthly or Annual payments
Please provide some details about the Home Building this is required to calculate your insurance premiums
Home Building Wall Construction*
Frame Construction*
Roof Construction*
Floor Construction*
Approximate year built*
Property Size in Acres*
Security Protection*

Deadlocks on all External doorsKey Operated Window Locks on all WindowsBars or Grills on all WindowsLocal AlamBack to Base AlarmNo SecurityNormal Key Locks only
Are you the Owner and Occupier of the Building
Please Provide some Details around the Sums insured and Cover Required (We require this to calculate your premium)
Building Sum Insured
Contents Sum insured
Unspecified Valuables Cover
Specified Valuables Cover
If you insure Farm Buildings, Fencing, Machinery or other Items Please provide details below
Current Limit of Liability for Farming Activities*
HISTORY DETAILS ( if you answer yes to any of the below questions please provide further information in free text box below)
Has the insured or any Directors had any claims in the last 5 years*
Has any Driver had any driving convictions of any kind in the last 5 years*
Has the insured or any Directors had any criminal convictions in the last 10 years*
Has the insured or any Directors had a claim refused, insurance declined or any special conditions imposed in the last 5 years*
Is the insured or any Directors aware of any circumstance that may lead to a claim*
CURRENT INSURER
Expiry Date of current Insurance or date to start cover

MonthDayYear
DISCLOSURE OF DRIVING CONVICTIONS
ANY OTHER INFORMATION PLEASE USE THIS TEXT BOX
ANY OTHER INSURANCE YOU WANT QUOTES ON SUCH AS BUSINESS,MOTOR, LANDLORDS, WORKERS COMPENSATION PLEASE USE THIS TEXT BOX
DUTY OF DISCLOSURE ( Please ensure all details are correct as answers on this form will be used to obtain quote and or cover and if incorrect or not disclosed information this could affect a claim being paid)
Should be Empty:

Farm Insurance Quote Form

Please provide some details about the Home Building this is required to calculate your insurance premiums

Please Provide some Details around the Sums insured and Cover Required (We require this to calculate your premium)

HISTORY DETAILS ( if you answer yes to any of the below questions please provide further information in free text box below)

DUTY OF DISCLOSURE ( Please ensure all details are correct as answers on this form will be used to obtain quote and or cover and if incorrect or not disclosed information this could affect a claim being paid)