Manufactured Homes

Please provide us with as much information as possible
to assist us in helping you with your enquiry.
However only items marked with (*) are required, once we have this information one of our
representatives will contact you to assist with your enquiry.

Last Name (*)

Please type your last name.

First Name (*)

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Address 1

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Address 2

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SUBURB (*)

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STATE (*)

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Postcode (*)

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Contact Telephone (*)

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Alternative Telephone

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Facsimile (if available)

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E-mail (*)

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How should we contact you?

E-mailPhoneMail

Park Name

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Site Address

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Brand of Home

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Type

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Model of Home

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Year Built

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No of Bedrooms

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Type of Roof

PitchedFlatTileColourbondOther

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Type of Cladding

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Security

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Additional Information

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No Claims Bonus

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Replacement Value

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Agreed Value

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Contents Replacement Cost

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Special Contents

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Special Contents Details

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Portable Personal Valuables

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Portable Personal Valuables Description

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Name of Financier

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Other Interested Party

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Questions Section

Has any insurer declined to insure you?

NoYes

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Has any insurer declined to renew a policy?

NoYes

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Have you ever been charged with insurance fraud?

NoYes

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Are you an undischarged bankrupt?

NoYes

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Have special conditions ever been set on a policy?

NoYes

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Has an increased excess ever been imposed

NoYes

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Have you had any prior claims rejected?

NoYes

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Details if YES to above

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Tell us of any criminal charges

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Who is your current insurer?

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Policy Number

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Will you be claiming a GST Input Tax credit?

NoYes

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If so what % of GST will you claim as ITC?

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Is there any unrepaired damage to the home

NOYES

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Unrepaired damage details

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Is there any unrepaired hail damage to the home

NOYES

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How did you find us

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Privacy Statement

Manufactured Homes Insurance Agency Ltd (MHIA) and its underwriters and representatives are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Private Sector Act 2000 (the Act)).  This sets out basic standards relating to the collection, use, disclosure and handling of personal information.

“Personal information” is essentially information or an opinion about a living individual whose identity is apparent or can reasonably be ascertained from the information or opinion.

Information will be obtained from individuals directly where possible.  Sometimes it may be collected indirectly.

Only information necessary for the arrangement and administration of MHIA’s business by MHIA and its underwriters and representatives will be collected.  This includes information necessary to accept the risk, to assess a claim and to determine competitive and appropriate premiums.  We will only ask for and take into account relevant information.

MHIA and its underwriters or representatives disclose personal information to third parties who they believe are necessary to assist them in doing the above.  These parties will only use the personal information for the purposes we provided it (or if required by law).

When you give MHIA and its underwriters or representatives personal information about other individuals, we rely on you to have made or make them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it.  If it is sensitive information we rely on you to have obtained their consent on these matters, before supplying us with the relevant information.

You are entitled to access information about you that we have relied on in making decisions that concern your insurance with us.  You will also have the opportunity to correct any mistakes or inaccuracies in the information we hold about you.  In special circumstances, we may decline to release information but we will not do so unreasonably.  Special circumstances may include, but are not limited to, information that is subject to privacy laws, information that is protected from disclosure by law, or where the release of the information may be prejudicial to us in relation to a dispute about your insurance.  Where we decline to release information, we will give you reasons and you will have the right to request us to review our decision through our complaints handling procedures.  We will provide our reasons in writing upon request.

Finally, you may also opt out of receiving materials sent by MHIA by contacting our office on (02) 4303 0300.  For the full text of our Privacy Policy, contact our office or refer to our website at http://www.mhia.com.au

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(*)

I have read understand and agree with the MHIA privacy statement.

You need to acknowledge the MHIA privacy policy to continue

Please verify that you are a real person

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Manufactured Home, Relocatable Home and Park Home Insurance Enquiry Form

Questions Section