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Motor Vehicle Drivers Declaration Form

Broker or dealer details

Conditions: (Please refer to the policy wording for full terms of cover)

  • Drivers under 25 years of age or over 80 years of age are excluded in all instances (other than the Excepted Persons described in the Policy Wording). In some cases drivers under the age of 30 will be excluded or cover is restricted to those approved and named on Your Policy Schedule e.g. in high value, exotic or high performance vehicles. Your policy schedule will advise the prescribed driver age required to be covered under this policy.
  • All regular drivers (2% or more usage) must be disclosed.
  • All Drivers must be the holder of an Australian issued Drivers Licence for a minimum of 5 years.

Driver(s) details & history

This policy covers Authorised Drivers – Please refer to the definition of Authorised Driver in the PDS.

Please list all regular drivers: (2% or more usage).

What is your current rating or NCB entitlement?
No Claim Bonus:

In the last five years have you or any of the drivers had any of the following?:

If yes to any of the above please provide full details below:
Medical conditions
Do you or any of the Authorised Drivers noted, currently suffer from or have suffered from in the last 5 years, any medical condition, or are currently dependant on or have you or they been dependant on in the last 5 years, any drug or medication which could affect your or their driving performance?:


Exceptional circumstances:

Unusual Terms

The policy you are applying for contains what may be considered unusual terms. These are listed in the Product Disclosure Statement (PDS). We strongly recommend that you read the PDS and the entire Policy Wording to make yourself familiar with all the terms and conditions of the Policy. All questions must be answered in full. If there is insufficient space to fully answer any question, please attach a separate sheet of paper. If you are unsure how to answer any questions, please contact your insurance adviser.


I/We agree on my own behalf and on behalf of all other insured persons that: the within statements are true. The Duty of Disclosure has been complied with. The Vehicle/Motorcycle described is and shall be maintained in an appropriate condition. When signing the Proposal/Quotation Form, I/We acknowledge that should some or all of the answers stated in this form NOT be in my/our own handwriting, the answers have been checked and I/We certify they are correct and that I/We agree to accept a policy subject to the terms, exceptions and conditions prescribed therein. The vehicle/motorcycle to be insured shall not be driven/ridden by any person under 30 years of age (or as otherwise prescribed on Your Policy Schedule). The vehicle/motorcycle to be insured shall not be driven/ridden by any person who to my/our knowledge has been refused any motor insurance or the continuance thereof. The Product Disclosure Statement (PDS) for this policy may be made available as described in the “Our Product Disclosure Statement” notice. I/We have read and agree to the terms of the Privacy Notice.

Important notices

  • This Insurance is underwritten by Certain Underwriters at Lloyd’s. The names and percentages of the applicable syndicates are available upon request to One Underwriting Pty Ltd. You can contact Lloyd’s in Australia at; Lloyd’s Underwriters’ General Representative in Australia, Level 9, 1 O’Connell Street, Sydney NSW 2000, Telephone (02) 8298 0700.
  • One Underwriting acts as an agent of Certain Underwriters at Lloyd’s in arranging and entering into this motor insurance, not the Insured.
  • This quotation is valid only for a period of thirty (30) days and may be withdrawn or varied at any time by us.
  • By submitting the request for quotation you confirm that you have read and agree to the terms of the Privacy Notice sent to you by us.
  • In submitting the information you are acting as agent of the proposed insured(s) and are doing so on their behalf.

Our Product Disclosure Statement

The law requires that you receive a “Product Disclosure Statement” (PDS) prepared by Certain Underwriters at Lloyd’s. The PDS aims to give you enough information to decide whether to buy this product. Lloyd’s PDS is made up of a number of documents. The Proposal and the PDS and Policy Wording Booklet contains the standard terms and conditions of cover. If cover is issued, the Schedule other documents we tell you are included, will update and becomes part of the PDS. These documents are available to you (if you or your agent does not already have them, by calling us, visiting our office or website:

Your Duty of Disclosure:

Before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 (Clth)to disclose anything that you know, or could reasonably be expected to know, that may affect our decision to insure you and on what terms. This includes your driving record and insurance history for the previous five (5) years and any criminal convictions whether current or spent for the previous ten (10) years prior to the inception of, or renewal of the insurance Policy.

You have that duty after proposal, and up until the time we agree to insure you. You have the same duty before you renew, extend, vary or reinstate a contract of insurance.

You do not need to tell us anything that:

  • reduces the risk that is insured;
  • is common knowledge;
  • Your insurer knows or should know as an insurer; or
  • the insurer waives compliance with your duty of disclosure.

If you are uncertain about whether or not a particular matter should be disclosed to the insurer, please contact Us or your appointed insurance broker.

Non Disclosure:

If you do not tell your insurer anything you are required to, the insurer may cancel your contract or reduce the amount that is required to pay you if you make a claim, or both. If your failure to disclose is fraudulent, the insurer may refuse to pay a claim and treat the contract as if it never existed.

Short Form Privacy Disclosure and Consent

  1. One Underwriting Pty Ltd is committed to protecting your personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). We collect, use and disclose personal information to offer, promote, provide, manage and administer our various insurance services we are involved in as set out in the One Underwriting Privacy Notice. In order to do this, we may also share your information with other persons or entities who assist us in providing or promoting our services as set out in the One Underwriting Privacy Notice. Further information about our privacy practices can be located in the One Underwriting Privacy Policy, a copy of which can also be sent to you on request by your One Underwriting representative. You may also gain access to your personal information, or modify your privacy preferences, by contacting your One Underwriting representative or our Privacy Officer through the means set out in the One Underwriting Privacy Notice.
  2. If you are disclosing personal or sensitive information about any other person to One Underwriting, you confirm that you have obtained the consent of that person to disclose to One Underwriting their personal or sensitive information and you have made them aware that One Underwriting will or may disclose their information to third parties that are reasonably necessary to assist in the provision of the relevant services or products. If you have not obtained consent from this other person to disclose their personal or sensitive information to One Underwriting, you will inform us before providing the relevant information to us.

By submitting this Quotation & Proposal Securus Motor Insurance, you acknowledge that you have read the One Underwriting Privacy Notice and agree that we can handle any personal information you have provided to us in the manner set out above Unless you tick here, we or any of our group of companies may be in touch by any means (including email or SMS) at any time to let you know about goods, services or promotions that may be of interest to you.

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