Please complete and submit the home quote form below to allow us to get you a competitive premium on your householders insurance.

Home Quote
Country Wide Branch:
Name: *
Date of Birth: *  
Street Address: *
Postcode: *
Phone Number: *
Email Address: *
Date of Insurance Due: *  
Level of Cover: *
Year of Construction: *
Construction Type: *
Occupancy: *
Building Sum Insured: $ *
Contents Sum Insured: $ *
 
Tick if fitted
Tick if not present
Keyed Window Locks:
Dead Locks on Doors:
Security Screens (Doors):
Security Screens (Windows):
Alarm (Local):
Alarm (Monitored):
Standard Door Locks:
Sliding Doors:
Tick if Bolted
Not Present
Window Shutters:
Tick if Bolted
Not Present
Safe Installed:
Mortgagee:
Do you require personal valuables covered anywhere in Australia ?
  Yes No If "Yes" then select
  $750 any one item /$2000 any one event
  $1000 any one item /$3000 any one event
  $1250 any one item /$5000 any one event
Any Claims last 5 years Yes No
- If "Yes", provide details in Comments below
Did you wish to specify any personal valuables or jewellery, paintings, antiques, curios or any special contents?
  Yes No
- If "Yes", provide details in Comments below
Comments:
 
   
 
* indicates Required Field