Couriers insurance package form

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1 Page 1 of 5 Couriers insurance package form Important Information 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 your 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 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. Short Form Privacy Disclosure and Consent Application/Claim Forms 1. One Underwriting Pty Ltd ( One ) 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 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 Privacy Notice. Further information about our privacy practices can be located in the One Privacy Policy, a copy of which can also be sent to you on request by your One representative. You may also gain access to your personal information, or modify your privacy preferences, by contacting your One representative or our Privacy Officer through the means set out in the One Privacy Notice. 2. If you are disclosing personal or sensitive information about any other person to One, you confirm that you have obtained the consent of that person to disclose to One their personal or sensitive information and you have made them aware that One 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, you will inform us before providing the relevant information to us. By submitting this Quotation, you acknowledge that you have read the One 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 or SMS) at any time to let you know about goods, services or promotions that may be of interest to you. Unless you tick here, we or any of our group of companies may be in touch by any means (including or SMS) at any time to let you know about goods, services or promotions that may be of interest to you. Do you Agree? Yes No This Policy is made up of three sections of cover, Motor Vehicle, General Liability and Marine Carriers Cover. It is a condition of a Quotation and/or Cover that a minimum of two sections are taken, one of which must be Motor Vehicle. Please indicate sections required: Commercial Motor Vehicle General Liability Marine Carriers

2 Page 2 of 5 Vehicle details The Insured Is the client currently insured through Aon Yes No Is the client currently insured with QBE Yes No If No, state the holding Underwriter Insured s Name and/or trading name/entity Insured s ABN/ACN No: Business Description: Location of Principal Depot: Number of years in business: Postal Address Street Suburb State Postcode In the last five years has any insurer declined any claim or proposal, cancelled or refused to renew a policy, or imposed special conditions Yes No Has any driver of the vehicle(s) had any convictions relating to alcohol, drugs, dangerous driving or failing to stop after an accident in the last five (5) years? Yes No In the last ten years been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, dangerous driving, fraud or violence against any person or property? Yes No Has any driver of the vehicle(s) had more than 4 traffic offences or more than one traffic offence, if the driver s age is under 25? Yes No If any of the above questions have been answer have been Yes, please be advised that we will not be able to provide you with a quotation as it is outside the insurer s underwriting guidelines. Have you ever alone or in partnership or jointly with any other party, or if a corporation, the corporation or any of its directors: Suffered any Motor Vehicle loss(es) (insured or otherwise) totalling more than $10,000 in the last 12 months or totalling more than $10,000 in the last three years or suffered two or more claims in any one policy year other than those declared in the claims section? Yes No In the last five years has any insurer declined any claim or proposal, cancelled or refused to renew a policy, or imposed special conditions Yes No In the last five years ever been placed in receivership or liquidation or declared bankrupt? Yes No

3 Page 3 of 5 Loss History Please provide the following current information: Have you suffered any motor vehicle claims or losses in the last 3 years? Yes No Note: please attach separate sheet where necessary Class Date of Loss Details of Claim Amount Excess No Claim Bonus NCB with current insurer Nil 10% 20% 30% 40% 50% 60% (Please attach proof of current NCB on your previous insurer s letterhead to bind cover) Motor Section Note: If more than one vehicle please complete for each vehicle requiring cover. Vehicle Details Registration Number Year Manufactured Model Number Vehicle Description Postcode Garaged Sum Insured (Covered for Market Value) Finance Type Radius of Operations Drivers date of birth Transmission Automatic Manual Vehicle Modified Yes No

4 Page 4 of 5 General Liability The Cover Courier Operators, including incidental storage/warehouse business activities (excluding Bulk Dangerous Goods) Limit of Indemnity $ Property in Physical or Legal Control $100,000 (refer Section 3 for exclusions) $ Underwriting Information Estimated Gross Freight Earnings (GFE) next 12 months $ Any other income $ If you use subcontractors, advise estimate of payments to subcontractors for next 12 months $ Total $ Do you manufacture, sell or promote any products? Yes No Are there any activities performed other than transporting of customers goods? Yes No Do you assume any liability or waive your rights under any contract or agreement? Yes No If you have answered Yes to any of these questions, please provide full details. Marine Carriers Underwriting Information Estimated Gross Freight Earnings (GFE) next 12 months $ Percentage as a principal contractor % Percentage as a contractor % If you use subcontractors, advise estimate to subcontractors for next 12months $ Cover Two levels of Cover are offered for Courier Operators (carrying non-owned freight only), the level of cover we provide will depend on your carrying conditions; Do you assume any liability or waive your rights under any contract or agreement? Yes No Do you operate under a consignment note?* Yes No * You must supply a copy of your consignment note to be eligible for Section 2(b) Sub Sections 2(a) Basic Cover available for all carriers, 2(b) Carriers using an appropriate consignment note Carriers Legal Defence Cover. Each of the Sub Sections provide a different type of cover, please refer to Section 2 of the Policy Wording for full details. Part 2 (a): Basic Cover applicable to all carriers

5 Page 5 of 5 Limit of Liability $500,000 We will cover you in relation to goods in the course of transit by you for either: 1. Responsibility for loss of or damage caused by an insured event for which you have assumed legal liability irrespective of legal liability or any terms or conditions of carriage, or 2. Any other legal liability for loss of or damage caused by an insured event. Part 2 (b): Carriers legal defence cover Carriers using approved terms and conditions (consignment note) Limit of Liability $500,000 The insurance cover provided by this Sub Section 2(b) applies to transits: 1. Where the consignor/owner accepts and signs your Approved Terms and Conditions and they apply to the transit; 2. Where by mistake, your Approved Terms and Conditions were not accepted and signed by the consignor/owner of the goods, but there is evidence that they had been accepted and signed by that same consignor/owner of the goods in the past and that there is an understanding that they apply to the transit. 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 signature Title Dated Submit your application Privacy policy. At One Underwriting we take privacy very seriously. For full details please refer to oneunderwriting.com.au/privacy One Underwriting ABN AFSL phone GPO Box 65, Brisbane Qld 4001 ONE0006I 0516

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