Insurance Application

By entering your details below a Insurance Express Adviser will get in touch with you. We will discuss with you how we can help you and then we’ll arrange a convenient time to meet.

1. Tick the type/s of Insurance I/we wish to apply for
2. Please select
3. House Contents Vehicle Health Life Commercial Landlord
4. Personal Info
5. Your Name *(required)
6. Date of Birth *(required)
7. Email Address *(required)
8. Contact Number
9. Mobile Number
10. Address *(required)
11. When can we contact you?
12. Preferred day to contact me
13. Preferred time to call me
14. If you are interested in house insurance
15. Size of Home
16. Type of construction, i.e. Brick & Tile
17. Is your home alarmed?
18. Water Supply:
19. Town water Supply Tank water Supply
20. If you are interested in contents insurance
21. Contents Value
22. Any high value items over $5,000?
23. If you are interested in vehicle insurance
24. Year
25. Make
26. Model
27. Value
28. Engine Size
29. Type of Licence
30. Have you had any claims in the last 3 years? If yes please provide details
31. If you are interested in life or health insurance
32. Gender
33. Male Female
34. Occupation
35. Height
36. Weight
37. Smoker?
38. No Yes
39. Are you currently experiencing problems or on medication
40. Any major medical history
41. Level of cover
42. Privacy Act
43. Pursuant to the Privacy Act 1993 the following is brought to your attention: 1. This authority enables us to collect personal information about you. 2. This information is collected to evaluate the insurance you seek. 3. The intended recipient of the information are: a. Mortgage Express Limited b. Any Underwriters of insurance c. Any Reinsurers of insurance d. Any agent of the above e. Insurance Claims Register Ltd 4. The information is being collected and held by Mortgage Express Limited and the underwriters of this insurance. 5. If you refuse to provide the information, the underwriters may decline your proposal. 6. You have rights to access to, and correction of, this information subject to the provisions of the Privacy Act 1993.
44. Declaration I/We declare that
45. 1. The sums insured represent full value of the property insured. 2. The premises are not used for business purposes. 3. I/We have not withheld any information likely to affect the acceptance of the purpose. 4. I/We agree that this proposal shall be the basis if the Contact between me/us and the Company, and I am/we are willing to accept cover subject to the Company's Policy conditions and special terms. 5. I/We have not had my/our Drivers Licence endorsed suspended or canceled during the last five (5) years.
46. I agree to the above declaration

 

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