Name *

First Name

Last Name

Delivery Date *

Select your preferred delivery date

MM

DD

YYYY

Name *

First Name

Last Name

D.O.B *

MM

DD

YYYY

When do you need your policy to start Cover? *

MM

DD

YYYY

Is the property heritage listed? *

Yes

No

Does the property have finance? *

Yes

No

Address of situation to be insured *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is this also the mailing address?

Yes

No

How many storeys is the dwelling? *

Single

Double

Triple

Other

If the property is older than 25 years, has it been re-wired or re-plumbed?

Yes

No

Is the property currently being renovated? *

Yes

No

Are the renovations greater than $50,000?

Yes

No

Is there a pool? *

Yes

No

Are there window locks? *

Yes

No

Dead locks on doors? *

Yes

No

Do you have an alarm?

Yes

No

Do you require content cover Australia-wide?

Yes

No

Do you want to pay for this policy monthly? (This will incur an interest cost). *

Yes

No

Would you like Archer to quote any other policies you may have? *

Yes

No