Email General Questions Situation of Risk First Name Last Name Unit Street City Postal Code Date of Birth Gender Male Female Have you had any claims in the last 5 years? Yes No Have you ever had insurance declined or special conditions imposed? Yes No Have you ever been convicted of a crime or declared bankrupt? Yes No General Questions Situation of Risk Insured Name Situation of Risk Building & Contents cover Loss of income required? Yes Is rental default cover required? Yes Is property owner responsible for glass? Yes Is liability cover required? Yes Is machinery cover required? Yes Construction details Brick / Concrete / Tile Wood Fire protection? Sprinklers Fire extinguishers Fire alarms Age of building (years)
