One Underwriting - Specialty Motor Proposal Form

Specialty Motor Proposal Form

Broker or dealer details
Company:
Name:
Phone:
Email:		Please enter a value.
Period of insurance
From:
To:
Occupation:
The applicant
Full name:
Overnight address
Street:
Suburb:
State:
Postcode:
Is the day parking address the same as overnight?:	Yes No If No please advise location
Street:
Suburb:
State:
Postcode:
Street:
Suburb:
State:
Postcode:
How is the vehicle parked overnight?:	Locked Garage Unlocked Garage Carport Driveway Car park On Street Other
Other:
How is the vehicle parked during the day?:	Locked Garage Unlocked Garage Carport Driveway Car park On Street Other
Other:
The cover
What type of cover?:	Daily Under 8 times per month Under 4 times per month Permanent on site Once per month Storage (not trading)
Vehicle details
Radius of operation:
Year:
Make:
Model:
Body type:
Capacity and cylinders:
Vin/Chassis number:
Registration number:
Purchase date:
Purchase price/value ($):
Modifations / Accessories (equipment)
Has your vehicle been modified?:	Yes No
If yes, describe all modifications and their values.:
Basis of Settlement
Do you wish to insure your vehicle for:	agreed value market value
If agreed value, at what value do you wish to insure your vehicle? (Including modifications and accessories i.e. proposed agreed value):	Please note we may not be able to offer agreed value in all instances and terms will be on market value basis only.
Finance
If yes, Name of provider:
Finance type:
Amount owing (if Hire Purchase or Loan, if Leased the unexpired term left). $:
Vehicle Security
Please provide details of any security devices fitted to the vehicle and security precautions at the declared overnight parking address:
Are you entitled to a No Claim Bonus or Discount?:	Yes No
No Claim Bonus:	Nil 10% 20% 30% 40% 50% 60% Rating 1 Protected
Description of Operations
Please select the appropriate activity type, if mixed please describe:	Hot Food Cold Food Coffee Vendor Mobile Bar Other
If Other, please provide details:
Year Business Started:
Fire Protection
Is there an automatic fire extinguishing system?:	Yes No
Please provide details:
If Yes, does it protect the following areas? (tick all that apply):	Deep Fat Fryers Range Hoods Cooking Surfaces
Is the Vehicle fitted with Fire Blankets?:	Yes No
If Yes, how many?:
Is the Vehicle fitted with Fire Extinguishers?:	Yes No
If Yes, how many?:
Are all Extinguishers appropriate for the operation type, e.g for deep frying operations Class F (Wet Chemical Class F, Powder Type BE):	Yes No
If No, advise reasons for non-compliance:
How many Deep Fryers are fitted?:
What is the maximum capacity in Litres of each?:
All people who will drive your vehicle (if powered unit only)
First name:
Family name:
Date of Birth:
% use:
First name:
Family name:
Date of Birth:
% use:
First name:
Family name:
Date of Birth:
% use:
First name:
Family name:
Date of Birth:
% use:
In the last 5 years, have you or any other person likely to drive your vehicle (if powered unit only)
Date of loss:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications:
Date of loss:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications:
Date of loss:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications:
Are there any additional traffic matters to disclose?:	Yes No
If yes provide details of all additional traffic matters.:
In the last 5 years, have you or any other person to be insured under this policy
Made a claim on any motor insurance policy?:	Yes No
Suffered a loss or damage to a motor vehicle for which you did not claim or were not insured for?:	Yes No
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss:
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss:
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss:
Are there any additional accident/claim matters to disclose?:	Yes No
If yes provide details of all additional accident/claim matters.:
Suffer from any illness or disability, likely to affect driving ability?:	Yes No
If yes, please provide details.:
Had any claims refused, insurance policy declined, cancelled or had special terms imposed?:	Yes No
If yes, please provide details.:
Declared bankrupt and not discharged within the last 12 months, or currently involved in bankruptcy or repossession proceedings?:	Yes No
If yes, please provide details.:
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?:	Yes No
If yes, please provide details.:
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 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 to be Insured shall not be driven by any person other than an Authorised Driver or an Excepted Person or as otherwise endorsed to Your Policy Schedule. The Vehicle to be Insured shall not be driven 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.
Applicant's Name:
Applicant's Signature:
Date:	Today
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. 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 and Terms of Business sent to You by Us. In submitting this 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 we make available our Target Market Determination (TMD) and 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 electronic declaration) 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 Application/ Claim Forms 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.
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Specialty Motor Proposal Form

Period of insurance

Overnight address

The cover

Vehicle details

Modifations / Accessories (equipment)

Basis of Settlement

Finance

Vehicle Security

Description of Operations

Fire Protection

All people who will drive your vehicle (if powered unit only)

In the last 5 years, have you or any other person likely to drive your vehicle (if powered unit only)

In the last 5 years, have you or any other person to be insured under this policy

Declaration

Important notices

Your Duty to take Reasonable Care not to Misrepresent

Short Form Privacy Disclosure and Consent