Securus Motor Insurance Quotation Form
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Securus Motor Insurance Quotation Form 

Broker or dealer details

Period of insurance

The applicant

Overnight address
Is the residential address the overnight parking location?:

If No please advise location?
How is the vehicle parked overnight?:

How is the vehicle parked during the day?:

The cover

What type of cover?:

* Important – limited use options exclude your vehicle being used on a daily or daily commuting basis

Vehicle details


Has your vehicle been modified?:

Do you wish to insure your vehicle for:

Are you entitled to a No Claim Bonus or Discount?:

No Claim Bonus:

Vehicle Use

For what purpose will you use your vehicle/motorcycle?:

All people who will drive your vehicle

You must nominate all people who will drive your vehicle i.e. those who will drive the vehicle more than 12 times a year. All drivers must have held an appropriate Australian Drivers Licence for more than 5 years. Drivers aged under 25 years (30 in some cases) and over 80 years are excluded or as specified on the schedule.

In the last 5 years, have you or any other person likely to drive your vehicle

Had any traffic offences, charges, infringements, convictions or disqualifications (excluding parking fines)?:

Are there any additional traffic matters to disclose?:

Made a claim on any motor insurance policy?:

Suffered a loss or damage to a motor vehicle for which you did not claim or were not insured for?:

If you have answered “Yes” to either question please describe the circumstances below.
Are there any additional accident/claim matters to disclose?:

Suffer from any illness or disability, likely to affect driving ability?:

Had any claims refused, insurance policy declined, cancelled or had special terms imposed?:

Declared bankrupt and not discharged within the last 12 months, or currently involved in bankruptcy or repossession proceedings?:

In the last 10 years, been convicted of, or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?:

Important notices

  • This Insurance is underwritten 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.
  • 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 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 (or declaration) 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:

Duty of Disclosure

Before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 (Cth) to disclose anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. You have that duty after proposal, and up until the time the insurer agrees 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 the insurer 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 broker.


If you do not tell your insurer anything you are required to, the insurer may cancel your contract or reduce the amount that it 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.

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