General Insurance Application

First Name *

Last Name *

Street Address *

Suburb

Town/City *

Country

Telephone *

Email *

Have you used a broker before?*

Yes No

Tick the type/s of Insurance I/we wish to apply for

House Contents Car Motorbike Boat Landlords Protection

A. House

1. Owner Occupied?

Yes No

2. Area in m2

3. Built before 1945?

Yes No

4. Is it a lifestyle property?

Yes No

5. Is the house used for any business purposes?

Yes No

B. Contents

1. Sum Insured

2. Any piece of jewellery, watch, or bike over $3000 list below, or art over $5000, please list below with name and value

3. Is there a professionally installed burglar alarm?

Yes No

C. Car

1. DOB of Driver (dd/mm/yyyy)

2. CC Rating

3. No Claims Bonus?

4. Year, Make and Model

5. Registration

6. Value

7. Type of Vehicle Insurance

D. Motorbike

1. DOB of Rider (dd/mm/yyyy)

2. Year, Make and Model

3. Registration

4. Value

5. Type of Motorbike Insurance

E. Boat

1. Type of Boat

2. Hull Construction

3. Hull Value

4. Motor (Year, Make, Model)

5. Motor (Horse Power)

6. Motor Value

7. Trailer

8. Trailer Value

9. Fixtures, Fittings and Equipment

10. Fixtures, Fittings and Equipment Value

11. Total Value

F. Landlords Protection

1. Property Street Address

2. Suburb

3. Town/City

4. Age of Property

5. Rent per week

Previous Insurance

1. Please enter the details of your previous Insurers(s)

1a. Renewal Date

2. Has any Insurance Company declined, required special terms, cancelled or refused to renew any insurance?

Yes No

If Yes, please give details

3. Have you had any claims in the last 3 years?

Yes No

If Yes, please give details

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. Aon Risk Services NZ 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 Aon Risk Services NZ 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.

Declaration I/We declare that

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 orioisal 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.

I agree to the above declaration

I give permission for my contact details to be used for sending me information about Mike Pero products and services that may be of interest to me.

Please enter code

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General Insurance Application

Personal Details

First Name *

Last Name *

Street Address *

Suburb

Town/City *

Country

Telephone *

Email *

Have you used a broker before

Insurance Types

A. House

1. Owner Occupied?

Street Address

Suburb

Town/City

Rental Properties

2. Area in m2

3. Built before 1945?

4. Is it a lifestyle property?

Business Purposes?

B. Contents

1. Sum Insured

Any piece of jewellery, watch, or bike over $3000 list below, or art over $5000

3. Is there a professionally installed burglar alarm?

C. Car

1. DOB of Driver (dd/mm/yyyy)

2. CC Rating

3. No Claims Bonus?

4. Year, Make and Model

5. Registration

6. Value

7. Type of Vehicle Insurance

D. Motorbike

1. DOB of Rider (dd/mm/yyyy)

2. Year, Make and Model

3. Registration

4. Value

5. Type of Motorbike Insurance

E. Boat

1. Type of Boat

2. Hull Construction

3. Hull Value

4. Motor (Year, Make, Model)

5. Motor (Horse Power)

6. Motor Value

7. Trailer

8. Trailer Value

9. Fixtures, Fittings and Equipment

10. Fixtures, Fittings and Equipment Value

11. Total Value

F. Landlords Protection

1. Property Street Address

2. Suburb

3. Town/City

4. Age of Property

5. Rent per week

Previous Insurance

Previous Insurers

1a. Renewal Date

refused_insurance

If Yes, please give details

Previous Claims

If Yes, please give details

Privacy Act

Declaration I/We declare that

I agree to the above declaration

Please enter code

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