Has any applicant been declared bankrupt and not discharged for at least one year?*
YesNo
If Yes, please supply details
During the last 5 years has any applicant had any type of loss or damage (whether claimed or not)?*
YesNo
If Yes, please supply details
Is the property to be insured attributable to flood?*
YesNo
During the past 5 years has any applicant had any:
(a) Application for insurance rejected?*
YesNo
If Yes, please supply details
(b) Policy cancelled by an insurance company?*
YesNo
If Yes, please supply details
(c) Special conditions set for your policy?*
YesNo
If Yes, please supply details
(d) Renewal of insurance policy not offered?
YesNo
If Yes, please supply details
(e) Increase excess imposed on your policy?*
YesNo
If Yes, please supply details
During the last 10 years has any applicant had any criminal conviction relating to drugs, dishonesty, arson, theft, fraud or violence against any person or property?*
YesNo
If Yes, please supply details