Add a House Adviser Name (if known) First Name Last Name What would you like us to do? (our Scope of Service) * Add a home to my existing policy Replace a home currently insured on my existing policy Create a new home policy Policy Number * Your Name * First Name Last Name Are you the owner of the home? * YES YES - jointly owned NO Whose name(s) should the insurance policy be in? (List details if owned by trust, company, body corporate) e.g. another person, company, trust Address of new home Address 1 Address 2 City State/Province Zip/Postal Code Country What date do you want cover effective from? MM DD YYYY House Details Before you start, here is a handy tool that could help you answer some of the questions needed to insure your home. Cordell Sum Sure Calculator - by entering your address, provides an estimate based on detailed information about your home Once you've completed this (or if you have obtained a written rebuild cost estimate from a registered value, registered quantity surveyor, building practitioner holding an appropriate trade licence), please email a copy to us at reception@kwa.nz It's important to set the sum insured at least as high as the written rebuild estimate and you will need a copy of this at claim time so keep it somewhere safe. Email us a copy of your Cordell Calculation or written rebuild cost estimate. This can be found under the Resources page then Calculators on our website. Is the Nominated Sum Insured: Inc GST Exl GST Not sure How have you arrived at the sum insured? Vero Cordell Calculator Other Cordell Calculator Insurance Valuation (this is NOT Market or Government value and should exclude land value) Quantity Surveyor Builder Other I have selected my own replacement value sum insured and it includes all improvements on the land (but not the land itself) such as the main dwelling, any garages, outbuildings, swimming pools, decks, fences, retaining walls, driveways, demolition costs and professional fees (e.g. architect, council permits). I acknowledge that my Adviser takes no responsibility for the sum insured figure that I have selected. Agree How is the home used majority of the time? Owner Occupied Home Owner Occupied Home and Rental Rental Property Holiday Home and Family Holiday Home and Casual Letting Unoccupied (if >30 days in total) Other What is the approximate size of the home in square metres? (Size of home including attached garaging and self-contained unit's - only excluding outbuildings or decks) Year built? Is the home on a lifestyle block or farm? YES NO What is the main type of home? Freestanding Attached Other Is this home part of a multi-unit or Body Corporate complex? YES NO Does this home have a monitored smoke or heat detector? YES NO Are there any entries against the certificate of title for this home? YES NO Is any form of business run from home? YES NO Are there any extra self-contained units? (own sleeping, cooking and bathroom facilities) YES NO Standard Excess ($) 500 (most popular) 400 (lowest) 750 1000 2500 5000 Mortgage with: None ANZ ASB BNZ Westpac Kiwibank Other Have you made any house (excluding contents) related insurance claims within the last 12 months? YES NO Contact Details First Name Last Name Postal Address (If different to one quoted above) Address 1 Address 2 City State/Province Zip/Postal Code Country Date of Birth MM DD YYYY Email Phone (###) ### #### Contact details of a second person Moral Questions Have you or your family members, or any other person or entity to be covered by the insurance: Made more than two claims in the last two years? YES NO Been aware of any damage from flooding, landslip or earthquake at any address relating to this policy? YES NO Had any insurance declined, cancelled, avoided, renewal refused, terms or conditions imposed or claim denied? YES NO Engaged in any criminal activity or had any criminal convictions, acquittals or diversions, or have any criminal prosecutions pending? YES NO Authorisation By ticking this box, I confirm I have read and understood the following authorisation statements On completion of this form our advisers will send you a Scope of Service and Disclosure Statement. If you have any questions prior to completing this form, please contact us. Additional notes or queries that may affect your insurance? By ticking this box and completing and submitting this proposal form, I/we declare that to the best of my/our knowledge and belief these particulars are true, complete and correct. Subject to any right I/we have under the Clean Slate Act, I/we have not withheld any information or any other material fact likely to affect the provision of cover. Is there anything else you would like assistance with? (we will contact you) KiwiSaver Home Loans Life/Health Insurance Domestic Insurance (e.g. contents, vehicle, boat, trailer, camper, van) Business Insurance Thank you! Book a free consultation Book consultation
