VEHICAL INSURE – INSURANCE APPLICATION FORM

Insurance

Select Insurance Type

Personal Information:

Title

First Name

Last Name

Date of Birth

Email ID

Mobile No.

Other Mobile No.

Address

Vehicle Details

	Vehicle 1
Make
Model
Year
Registration
Market Value NZ$(excluding GST)
Type of Cover Required
Loss of Income Cover Required (Yes/ No)
Vehicle Security Details
Vehicle Parked
Vehicle Alarmed
Vehicle Immobilizer Installed

Driver's Details

	Principal Driver
First Name
Last Name
Date of Birth
NZ Full License Issue Year

Duty Of Disclosure (Please answer the following in "Yes" or "No")

1	Has any Insurer ever refused a proposal you have made for insurance, or have you ever had a policy cancelled, renewal refused or special terms imposed: :	If yes,Please give details below
2	Have you or any other insured party ever withdrawn a claim, or had a claim declined by an insurer: :	If yes,Please give details below
3	Have you or any other insured party ever been declared bankrupt, been placed in receivership or liquidation, or been sued for unpaid debts:	If yes,Please give details below
4	Subject to the Criminal Records (Clean Slate) Act 2004, have you or any other insured party been convicted, charged, or have a prosecution pending for any criminal offence:	If yes,Please give details below
5	Have you or any other insured party had any motor accidents, damages or thefts in the last 3 years (whether a claim was made or not)?	If yes,Please give details below
6	Are you aware of any circumstances, other than those mentioned above, which could influence the Insurers decision to accept the risk of insurance, or which could alter the terms of such decision?	If yes,Please give details below

Privacy Legislation and Declaration

1.Pursuant to the Privacy Act 1993 the following is brought to your attention. 2.We have collected information about you in the process of providing you with this Insurance Report. . 3.The information has been collected to evaluate the insurance you seek, and will be used to assist in administering your policy and managing any claims. 4.The information is required pursuant to the common law duty to disclose all material facts relevant to the insurance sought and is mandatory. 5.You have the right of access to and correction of this information, subject to the provisions of the Privacy Act 1993.

Do you authorise us to give to, or obtain from, Insurers or any other reference service including the Insurance Claims Register Ltd, information relating to the insurance held by you, or any claims in relation thereto: ?
I/We agree the Privacy Policy Statement is acceptable:

1. I/We hereby declare that all the answers and statements made in this declaration and as shown on the schedule, are true and accurate in every respect and no information has been withheld which is likely to affect an Insurer’s decision on this insurance and/or on what terms and conditions. 2. I/We have read and understand all the information contained in the schedule and this declaration, including the Duty of Disclosure obligations and agree it is as I/we require. 3. I/We understand this Insurance Report is a summary and is not the policy wording and that I/we have been recommended to read the policy wording. 4. I/We undertake to advise of any material alteration of the information disclosed whether occurring before or after the insurance cover commenced. 5. I/We acknowledge that the Insurer reserves the right to decline any application. 6. I/We understand that this declaration will be relied on by the Insurer in accepting my/our application. 7. I/We authorise the Insurer to give and obtain from other Insurance Companies, Insurance Brokers, the Insurance Claims Register Ltd or any other party any information relating to this or any other insurance held or previously held by me/us. 8. I/We declare that in conformance with Section 48 (6) of the Fire Service Act 1975, the indemnity value of the asset/s listed and insured is fair and reasonable in relation to the replacement value of the asset/s.

"I confirm that above is true to the best of my Knowledge".

"I want the Insurance Excess Reimbursed up to $1000 at the time of claim".

VEHICAL INSURE – INSURANCE APPLICATION FORM
This is an application for insurance. Insurance does not commence until the proposal has been accepted by an insurance company and confirmed to you in writing by us and premium is paid or agreed to be paid.
We are required to provide a Duty of Disclosure notice to you. Our Policy Quotation is based on information you have supplied. Please ensure that you have carefully read all Duty of Disclosure questions prior to signing the declaration. Your Duty of Disclosure requires you to tell us the relevant information that may affect the decision to provide insurance cover and/or the terms and conditions of the insurance. Each person(s) or entity named as the Insured has this duty of disclosure. Any Non-Disclosure of relevant information may result in the refusal of claims and/or cancellation of the insurances.
Private use is Named Drivers Only

VEHICAL INSURE – INSURANCE APPLICATION FORM

Private use is Named Drivers Only