Landlords Insurance Application Form
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Landlords Insurance Application Form

Please complete the attached application form and a broker will contact you shortly.

Complete All Fields
  • Name/s
  • Postal address
  • Business Phone number
  • Mobile Phone number
  • Insured Name
  • Insured Property Location
  • Email
  • Cover to commence
  • Has any insurer refused or cancelled cover or required special terms to insure you?
    Yes
    No
  • Have any of the applicants or any person who will recieve insurance cover under the proposed policy, been charged with, or convicted of any criminal offences during the last 10 years?
    Yes
    No
  • Has or will the property be unoccupied for more than 90 days?
    Yes
    No
  • Will the property be used for anything other than residential purposes?
    Yes
    No
  • How old is the building?
  • Contents cover required
    $20,000
    $55,000
  • I declare that I have read Whitbread Insurance Brokers FSG, the Insurer's PDS and complied with my Duty of Disclosure as per the Insurance Contracts Act 1984.
    Yes
    No
  • Security question