One Underwriting - Secure 4x4 Motor Insurance quotation & proposal 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 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.

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This quotation is valid only for a period of thirty (30) days and may be withdrawn or varied at any time by Us.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

I agree.

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 endeavoured 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 Quotation & Proposal 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. I agree for One Underwriting Pty Ltd or Aon to send me information about its goods, services and promotions via email or phone.

I agree.

Broker or dealer details
Company:
Name:
Phone:
Email		Please enter a value.
Period of insurance
From:
To:
The applicant
Full name:
Occupation:
Email
Phone:
Enthusiast Club Membership (are you a financial member of an 4x4 or off-road club/association):	Yes No
If yes, state club and membership number:
Postal address
Street:
Suburb:
State:
Postcode:
Residential address
Street:
Suburb:
State:
Postcode:
Is the residential address the overnight parking location?:	Yes No
If No please advise location?
Street:
Suburb:
State:
Postcode:
How is the vehicle parked overnight?:	Carport Driveway Locked Garage (Commercial Property) Locked Garage (Residential) Locked Garage (Residential Communal) Unlocked Garage (Residential Communal) Unlocked Garage On Street Other
Other:
Is the day parking address the same as overnight?:	Yes No
If No please advise location
Street:
Suburb:
State:
Postcode:
How is the vehicle parked during the day?:	Carport Driveway Locked Garage (Commercial Property) Locked Garage (Residential) Locked Garage (Residential Communal) Unlocked Garage (Communal) Unlocked Garage Manned Private Car Park Manned Public Car Park Unmanned Private Car Park Unmanned Public Car Park Street
Other:
The cover
If the vehicle is not driven on a regular basis You can select an annual kilometer limitation in return for a premium saving. In choosing a limited annual kilometer option you agree to advise Us if You will exceed the limitation without delay. If You exceed the kilometer limitation an additional premium and/or excess may be payable. If you are insured for Concessional/Club registration and increase the vehicle’s registration status to full registration without informing Us, You may not be insured.
What type of cover?:	Comprehensive – (Daily & Commuting Use) Comprehensive – limited <8,000km per year Comprehensive – concessional cover/club registration
If you are requesting a reduced usage cover i.e. Limited Use or Extreme Limited Use, please complete the following
What is the current Odometer Reading?:
Is the Odometer functioning correctly?:	Yes No
Vehicle details
Year:
Make:
Model:
Body type:
Capacity and cylinders:
Engine number:
Vin/Chassis number:
Registration number:
Purchase price/value ($):
Purchase date:
Modifications: Means that your vehicle has alterations to the engine, drive train, suspension or wheels other than by the manufacturers design. Accessories: An accessory is an item fitted by a dealer or non standard item or items not fitted by the manufacturer, such as tinted windows, alloy wheels and other fixed items which do not affect the performance or handling of the vehicle.
Has your vehicle been modified?:	Yes No
If yes, describe all modifications and their values.
Does your vehicle have any non-standard accessories?:	Yes No
If yes, describe the accessories and their values.
Do you have a security device fitted?:	Yes No
If yes, please provide details.:
How would you rate the overall vehicle condition?:	New vehicle Average or less, requires restoration Good for its age condition Classic vehicle – newly restored/concours
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):
Optional and Additional Benefits(additional Premium may apply, if We agree to cover they will be noted on Your quote and Policy Schedule)
Camping Equipment - Are there additional items to be insured in excess of $150 per item or $3,000 in total? :	Yes No
If yes, describe the accessories and their values.:
Windscreen Cover - (removal of Basic Excess for first Windscreen Glass Claim per Period of Insurance) :	Yes No
Hire Vehicle after an Insured Event - (provides cover for a hire vehicle in the event of an Insured Event for up to 14 days/$100 per day maximum or where an approved repairer is used and We arrange a Courtesy Vehicle for you up to 30 days).:	Yes No
Finance:	Yes No
Name of provider:
Finance type:
Amount owing (if Hire Purchase or Loan, if leased the unexpired term left.):
Has the vehicle been uninsured during the last 30 days?:	Yes No
If yes, please provide details why not.
Are you entitled to a No Claim Bonus or Discount? (copy required to be attached to this application for insurance):	Yes No
No Claim Bonus:	Nil 10% 20% 30% 40% 50% 60% Rating 1 Protected
Insurer Name:
Policy Number:
Vehicle Use
For what purpose will you use your vehicle/motorcycle?:	Private Business Wedding Hire Other
For use other than Private, please provide details
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.
1.
First name:
Family name:
Date of Birth:
Year Licence Obtained:
Licence No:
% use:
2.
First name:
Family name:
Date of Birth:
Year Licence Obtained:
LicenceNo:
% use:
3.
First name:
Family name:
Date of Birth:
Year Licence Obtained:
Licence No:
% use:
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)?:	Yes No
1.
Date of incident:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications
2.
Date of incident:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications:
3.
Date of incident:
Person involved:
Amount of fine, penalty or disqualification period:
Details of charges, offences, infringements, convictions or disqualifications
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
If you have answered “Yes” to either question please describe the circumstances below.
1.
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss
2.
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss:
3.
Drivers name:
Person at fault:
Cost ($):
Date of loss:
Insurer:
Details of loss
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.
Are you an Aon employee or the domestic partner/sibling thereof, or reside permanently at the home address of such?:	Yes No

Secure 4x4 Insurance Quotation Form

Broker or dealer details

Period of insurance

The applicant

Residential address

The cover

Vehicle details

Vehicle Use

All people who will drive your vehicle

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

Declaration

Important notices

Our Product Disclosure Statement

Short Form Privacy Disclosure and Consent