Specialty Motor Proposal Form
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Specialty Motor Proposal Form

Broker or dealer details

Period of insurance

The applicant

Overnight address
Is the day parking address the same as overnight?:

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?:





Vehicle details

Modifations / Accessories (equipment) 
Has your vehicle been modified?:

Basis of Settlement

Do you wish to insure your vehicle for:

Please note we may not be able to offer agreed value in all instances and terms will be on market value basis only.

Finance

Vehicle Security

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

No Claim Bonus:







Description of Operations

Please select the appropriate activity type, if mixed please describe:




Fire Protection

Is there an automatic fire extinguishing system?:

If Yes, does it protect the following areas? (tick all that apply):


Is the Vehicle fitted with Fire Blankets?:

Is the Vehicle fitted with Fire Extinguishers?:

Are all Extinguishers appropriate for the operation type, e.g for deep frying operations Class F (Wet Chemical Class F, Powder Type BE):

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)

Are there any additional traffic matters to disclose?:

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?:

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

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?:

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.

Today

Important notices

  1. 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.
  2. One Underwriting acts as an agent of HDI Global Specialty SE - Australia in arranging and entering into this motor insurance, not the Insured.
  3. This quotation is valid only for a period of thirty (30) days and may be withdrawn or varied at any time by Us.
  4. 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.
  5. 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 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 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

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.



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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