Diyadio WebForms :: Webform Designer

Form name:

<div class="rounderCornerMiddle">
    <div id="wrapper">
        <div class="headerText">
            HOUSE AND CONTENTS INSURANCE PROPOSAL
        </div>
        <div>
            <strong>No risk attaches until the proposal has been accepted by the company and premium
                is paid or agreed to be paid </strong>
        </div>
        <fieldset>
            <legend>Your Details </legend>
            <div class="itemField">
                <div class="listDiv2">
                    Full Name:<span class="redText">*</span>
                </div>
                <div class="listDiv">
                    <input type="text" name="txbFullName" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Address:<span class="redText">*</span>
                </div>
                <div class="listDiv">
                    <textarea name="txbAddress" cols="22" rows="4"></textarea></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Occupation:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbOccupation" /></div>
            </div>
            <div class="itemField">
                Contact details:
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Postal Address:
                </div>
                <div class="listDiv">
                    <textarea name="txbPostalAddress" rows="4" cols="22"></textarea></div>
            </div>
            <div class="itemField">
                Telephone</div>
            <br />
            <div class="itemField">
                <div class="listDiv2">
                    Work:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbWork" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Home:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbHome" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Mobile:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbMobile" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    E mail:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbEmail" /></div>
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR DUTY OF DISCLOSURE</legend>
            <div class="itemField">
                You must tell us everything you know (or could be reasonably expected to know) that
                a prudent insurer would want to take into account in deciding:
                <ul>
                    <li>Whether to accept your proposal, and</li>
                    <li>so, on what terms.</li>
                </ul>
                Examples of what you must tell us include:
                <br />
                <ul>
                    <li>Anything that increases the risk of a claim</li>
                    <li>Any criminal offending or convictions</li>
                    <li>Any previous insurance claims</li>
                    <li>Any refusal by another insurer to insure you on standard terms, or continue to insure
                        you on standard terms </li>
                </ul>
            </div>
        </fieldset>
        <fieldset>
            <legend>Your Privacy </legend>
            <div class="itemField">
                We collect and receive your personal information in this proposal to decide whether
                to insure you. We hold it in our records. You have rights to access it, and correct
                it under the Privacy Act 1993.
                <br />
                <br />
                You must supply your personal information to us if it comes within your duty of
                disclosure (see Your Duty of Disclosure above). If you fail to do so, we may decline
                your proposal or avoid your insurance retrospectively. We obtain your authority
                below to transfer some or all of it to other members of the insurance industry,
                financially interested parties noted on your policy and Insurance Claims Register
                Limited.
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR PREVIOUS HISTORY</legend>
            <div class="checkboxItemField">
                <label>
                    Has any insurer ever refused to insure you on standard terms, or refused to renew
                    your insurance on standard terms?</label>
                <input type="radio" name="rbtnInsurer" value="Yes" />
                <input type="radio" name="rbtnInsurer" value="No" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Has any insurer ever refused to pay your insurance claim?</label>
                <input type="radio" name="rbtnInsurenceClaim" value="Yes" />
                <input type="radio" name="rbtnInsurenceClaim" value="No" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Have you made any insurance claim in the last five years?</label>
                <input type="radio" name="rbtnInsurenceinFiveYears" value="Yes" />
                <input type="radio" name="rbtnInsurenceinFiveYears" value="No" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you know of any circumstances that could lead to a claim under any of our policies
                    in the future?</label>
                <input type="radio" name="rbtnCircumstances" value="Yes" />
                <input type="radio" name="rbtnCircumstances" value="No" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you have any criminal convictions (including traffic offences, but not parking
                    offences), or are you currently facing a prosecution?</label>
                <input type="radio" name="rbtnCriminalConvictions" value="Yes" />
                <input type="radio" name="rbtnCriminalConvictions" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If yes, please list each offence or prosecution, and each sentence your business
                    has received.
                </div>
                <div class="listDiv">
                    <textarea name="txbCriminalConvictions" rows="4" cols="55"></textarea></div>
            </div>
            <div class="itemFiled">
                <div class="listDiv2">
                    If you have answered yes to any of the above questions, please write full details
                    below</div>
                <div class="listDiv">
                    <textarea name="txbAnswers" rows="5" cols="45"></textarea></div>
            </div>
        </fieldset>
        <fieldset>
            <legend>HOUSE INSURANCE </legend>
            <div class="itemField">
                <span class="blueBolderText">Please complete this section if you require House Insurance.</span></div>
            <div class="checkboxItemField">
                <label>
                    Is your property</label>
                <input type="radio" name="rbtnProperty" value="Detached house" />
                <input type="radio" name="rbtnProperty" value="Flat/apartment" />
                <input type="radio" name="rbtnProperty" value="Home unit" />
                <input type="radio" name="rbtnProperty" value="Part of a residential only body corporate" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    How many buildings are on the property?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbProperties" /></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Who occupies your property?</label>
                <input type="radio" name="rbtnOccupies" value="You and your family members and/or others" />
                <input type="radio" name="rbtnOccupies" value="Relatives/employees" />
                <input type="radio" name="rbtnOccupies" value="Tenants" />
                <input type="radio" name="rbtnOccupies" value="Unoccupied" />
            </div>
            <div class="checkboxItemField">
                <label>
                    If tenanted, do you or an agent inspect the property regularly?</label>
                <input type="radio" name="rbtnTenanted" value="Yes" />
                <input type="radio" name="rbtnTenanted" value="No" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Has there been any damage resulting in an insurance claim in the last five years?</label>
                <input type="radio" name="rbtnDamageResulting" value="Yes" />
                <input type="radio" name="rbtnDamageResulting" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    When was your house built?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbHouseBuilt" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    What is the house size (floor area in square meters)?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbHouseSize" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    What is the present value of the house (excluding the land value)?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbPresentValue" /></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you know the replacement value?</label>
                <input type="radio" name="rbtnReplacement" value="Yes" />
                <input type="radio" name="rbtnReplacement" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If so please advise :
                </div>
                <div class="listDiv">
                    <textarea name="txbReplacementAdvise" rows="4" cols="35"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you use the property as a business or trade?</label>
                <input type="radio" name="rbtnPropertyTrade" value="Yes" />
                <input type="radio" name="rbtnPropertyTrade" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If Yes, please describe.</div>
                <div class="listDiv">
                    <textarea name="txbPropertyDescribe" rows="4" cols="35"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Does the property require repairs?</label>
                <input type="radio" name="rbtnPropertyRequire" value="Yes" />
                <input type="radio" name="rbtnPropertyRequire" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If so, please list.
                </div>
                <div class="listDiv">
                    <textarea name="txbPropertyRepairsList" rows="4" cols="35"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Are you currently renovating any of the property?</label>
                <input type="radio" name="rbtnCurrnetlyRenovating" value="Yes" />
                <input type="radio" name="rbtnCurrnetlyRenovating" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If so, please list</div>
                <div class="listDiv">
                    <input type="text" name="txbList" /></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Has the property ever suffered flooding or landslides</label>
                <input type="radio" name="rbtnSufferedFlooding" value="Yes" />
                <input type="radio" name="rbtnSufferedFlooding" value="No" />
            </div>
        </fieldset>
        <fieldset>
            <legend>CONTENTS INSURANCE </legend><span class="blueBolderText">Please complete this
                section if you require Contents Insurance. </span>
            <div class="itemField">
                <div class="listDiv2">
                    Please list the address of where the contents are stored:
                </div>
                <div class="listDiv">
                    <textarea name="txbContentsStoredAddress" rows="4" cols="22"></textarea></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Who owns the property where your contents are located?
                </div>
                <div class="listDiv">
                    <textarea name="txbWhosProperty" rows="4" cols="22"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    If it is your home, what type of property is it?</label>
                <input type="radio" name="rbtnPropertyType" value="Main home" />
                <input type="radio" name="rbtnPropertyType" value="Holiday home" />
                <input type="radio" name="rbtnPropertyType" value="Tenanted property" />
                <input type="radio" name="rbtnPropertyType" value="Unoccupied" />
            </div>
            <div class="checkboxItemField">
                <label>
                    If you don't own the property, are you:</label>
                <input type="radio" name="rbtnDontOwn" value="Living alone and/or with family" />
                <input type="radio" name="rbtnDontOwn" value="Have flat mates" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Who else requires contents cover?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbRequiresContents" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    What is the total value of the contents insured?
                </div>
                <div class="listDiv">
                    <input type="text" name="txbTotalValue" /></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Does the property have a burglar alarm?</label>
                <input type="radio" name="rbtnPropertyBurglar" value="Yes" />
                <input type="radio" name="rbtnPropertyBurglar" value="No" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If so, please describe.
                </div>
                <div class="listDiv">
                    <textarea name="txbBurglarAlarm" rows="4" cols="35"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you have deadlocks on the doors/windows?</label>
                <input type="radio" name="rbtnDeadlocks" value="Yes" />
                <input type="radio" name="rbtnDeadlocks" value="No" />
            </div>
            <div class="itemField">
                Please read the policy for specific limits on the sums insured for certain contents.
                Please contact us if any of the items are valued in excess of those individual limits
                and you require additional cover.
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR DECLARATION </legend>
            <div class="itemField">
                <span class="blueBolderText">I declare that I: </span>
                <ul>
                    <ol>
                        1. Have answered all questions truthfully.
                    </ol>
                    <ol>
                        2. Have, in addition, disclosed all material facts to New India (please see your
                        duty of disclosure above)
                    </ol>
                    <ol>
                        3 Agree to the policy terms and conditions.
                    </ol>
                    <ol>
                        4 Authorize:
                    </ol>
                    <ul>
                        <ol>
                            4.1 New India to advise me of its other services from time to time.
                        </ol>
                        <ol>
                            4.2 The disclosure of my personal information held by New India to:
                        </ol>
                        <ul>
                            <ol>
                                4.2.1 Other members of the insurance industry, and
                            </ol>
                            <ol>
                                4.2.2 Financially interested parties noted on the policy, and
                            </ol>
                            <ol>
                                4.2.3 Insurance Claims Register Limited.
                            </ol>
                        </ul>
                        <ol>
                            4.3 The disclosure of my personal information held by:
                        </ol>
                        <ul>
                            <ol>
                                4.3.1 Other members of the insurance industry, and
                            </ol>
                            <ol>
                                4.3.2 Insurance Claims Register Limited to New India for the purpose of considering
                                this proposal and administering the policy.
                            </ol>
                        </ul>
                    </ul>
                </ul>
            </div>
        </fieldset>
    </div>
</div>