QUOTE FORM CPLI

INSURED'S Details

Proposed Policy Holder Full Name/s*

Project Street Number & Street Name*

Post Code*

City/Town*

PROJECT Details

Type of work to be performed*

Building type*

Construction material*

Project arranged by*

If you selected "Registered / Licenced Builder or Project Manager" above, please include the builders name below

Have the works commenced*

Yes
No

If YES, have the works exceeded the Slab/Base/Foundation stage

Yes
No

Project start date (estimated)*

Height of works*

Construction period*

Maximum excavation depth*

Total area of building/s in sq/m*

Is the site connected to mains water supply?*

Yes
No

Does the property have any water tanks, dams, etc, connect to fire pumps?*

Yes
No

The distance from the property to the nearest Fire Station:*

Under 10 km's
Over 10 Km's

Shortest distance to any land boundary*

A basement*

Yes
No

Steep block*

Yes
No

Demolition*

Yes
No

Piling or underpinning*

Yes
No

Local council heritage overlay*

Yes
No

Reclaimed land*

Yes
No

Below or over water table*

Yes
No

National heritage or historic land*

Yes
No

Adjoining property protection orders (VIC ONLY)*

Yes
No

Swimming pool*

Yes
No

Blasting*

Yes
No

Welding or flame cutting activities*

Yes
No

A special foundation*

Yes
No

INSURANCE Details

Total cost of the project in Australian Dollars*

(Total replacement cost of the completed works)

Existing Building Sum Insured in Australian Dollars (please complete even if the value is $0)*

Often building insurance (e.g. home insurance) does not provide cover while a building is under construction. We recommend existing building insurance

Public liability*

PREVIOUS INSURANCE Details

Have you ever suffered any losses or claims?*

Yes
No

Please confirm if you have suffered any accidents or incidences that would give rise to a claim under this insurance?*

Yes
No

Have you ever had any insurance cancelled or declined or special terms imposed?*

Yes
No

Have you ever been charged or convicted of any criminal offence or declared bankrupt?*

Yes
No

Are you aware of any matters not disclosed above that are relevant to the underwriter's consideration of this insurance?*

Yes
No

Please provide all relevant information to all questions answered “Yes”. Please include where applicable, dates, insurance companies, amounts claimed, and other information that may be relevant to the consideration of this insurance.

CONTACT Details

Name*

First Last

Contact Postal Address same as Project Address?*

Yes
No

If you answered NO above, please enter contact address

Street Address Address Line 2 City State Postal Code

Phone number*

(Please include area code)

Email*

How did you find us?*

Comments

CPLI QUOTE FORM

INSURED'S Details

PROJECT Details

INSURANCE Details

PREVIOUS INSURANCE Details

CONTACT Details