Completing this online Proposal Form

Please answer all questions giving full and complete answers.
It is the duty of the proposer to provide all information that is requested in this Proposal Form as well as to disclose relevant facts. A relevant fact is a known fact or circumstances that may influence the evaluation of risk by the insurer. If you are uncertain about what a relevant fact is, please contact us.
If renewing an existing policy with Express Insurance, please ensure you check all information and make any necessary changes.

Insured Details

Insured Name / Host:

Contact Phone Number

Email address

Re-enter Email address

Address details

I am unable to find the address

Street Number/ Name:

Suburb:

Postcode:

State:

What is the maximum number of students who will be hosted at any one time?
Note: The maximum number of students covered by the policy is 5. If you host more than 5 students at a time you can not purchase this policy.

Period of Insurance

Policy Start Date