One Underwriting - Motor Vehicle Drivers Declaration Form

Declaration

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. In submitting this form, I/We acknowledge 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.

I agree.

Important notices

This Insurance is underwritten by HDI Global Specialty SE - Australia, (ABN 58 129 395 544, AFS Licence number 458776), with its registered address at Tower 1, Level 33, 100 Barangaroo Avenue, Sydney NSW, 2000. Telephone (02) 8373 7580.
One Underwriting acts as an agent of HDI Global Specialty SE - Australia in arranging and entering into this motor insurance, not the Insured.
By submitting this declaration 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 HDI Global Specialty SE - Australia. The PDS aims to give You enough information to decide whether to buy this product. The PDS is made up of a number of documents. The Proposal and the PDS and Policy wording contains the standard terms and conditions of cover. If cover is issued, the Policy 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: oneunderwriting.com.au)

Your Duty to take Reasonable Care not to Misrepresent

You have a duty to take reasonable care not to make any misrepresentation when entering into, varying, extending or renewing the Policy.

This means that it is essential that You respond to specific questions that We ask honestly and to the best of Your knowledge, including where We ask You to confirm or update information that You have previously given to Us when entering into, varying, extending or renewing the Policy.

For example this will include You or any other persons to be covered under this Policy and their driving record, claims (or incidents unclaimed or uninsured for), criminal and insurance history. This duty also extends to, but not limited to how Your Vehicle is Garaged, registered or used in frequency and nature of use for example Private Use, Business Use or otherwise.

To assist You with providing Us with honest and accurate responses to any questions We ask of You, We have endeavored to ensure that any question We ask are clear and easy to understand. Further, where possible, We have also included examples of the types of responses We are looking for when asking a particular question.

If You are unclear of any particular question or would like Us to explain it to You, please get in touch with Us and We will explain this to You.

In determining whether You have fulfilled this duty to take reasonable care not to make a misrepresentation to Us, We will consider all of the relevant circumstances of a particular case. If You do not respond honestly and accurately to specific questions that We ask, We may (acting reasonably) cancel Your contract or reduce the amount We will pay You if You make a claim, or both. It is therefore vital that You be honest and specific in Your responses. If Your failure to tell Us is fraudulent, We will refuse to pay a claim and treat the Policy as if it never existed (this does not mean that We will refund any premiums that You have already paid).

Short Form Privacy Disclosure and Consent

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.
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 declaration, 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.

I agree.

Broker or dealer details
Company:
Name:
Phone:
Email:
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.
Policy Number:
Policy expiry date:	Today
Driver(s) details & history
Registered owner(s) name:
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).
1.
Name:
Sex:
Date of birth:
License Type:
Date Obtained:	Today
Occupation:
Relationship to Insured:
% Use:
2.
Name:
Sex:
Date of birth:
License Type:
Date Obtained:	Today
Occupation:
Relationship to Insured:
% Use:
3.
Name:
Sex:
Date of birth:
License Type:
Date Obtained:	Today
Occupation:
Relationship to Insured:
% Use:
4.
Name:
Sex:
Date of birth:
License Type:
Date Obtained:	Today
Occupation:
Relationship to Insured:
% Use:
What is Your current rating or NCB entitlement?
No Claim Bonus:	Nil 10% 20% 30% 40% 50% 60% 60% Rating 1 Protected
In the last five years have you or any of the drivers had any of the following?:	Accidents or Claims (incl. vehicles burnt or stolen) Motor offence, on the spot fine or camera fine Licence suspended, cancelled or endorsed Insurance Refused or Declined or special terms imposed Any conviction or charge pending Been declared bankrupt Claim Denied
If yes to any of the above please provide full details below:
Driver’s name:
Date of loss or offence:	Today
Cost ($):
Circumstances – explain accident details and offence type, demerit points lost. If licence suspended or cancelled, please specify for how long.
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?:	Yes No
Details
Exceptional circumstances
Are there any exceptional circumstances that exist? An exceptional circumstance is any matter the proposed insured knows and that a reasonable person in the circumstances could be expected to tell Us that is relevant to Our decision to insure them and whether any special conditions need to apply that We could not reasonably have been expected to make the subject of a specific question. Please attach Your response on a separate piece of paper if the space provided is insufficient.
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.

Motor Vehicle Drivers Declaration Form

Broker or dealer details

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

Driver(s) details & history

Medical conditions

Details

Exceptional circumstances

Unusual Terms

Declaration

Important notices

Our Product Disclosure Statement

Your Duty to take Reasonable Care not to Misrepresent

Short Form Privacy Disclosure and Consent