commercial motor vehicle insurance application

Transcription

1 commercial motor vehicle insurance application

2 CGU Insurance Limited ABN lease read this page together with the roduct Disclosure Statement and olicy booklet before you complete the application, and retain these documents so you can refer to them again. What you need to tell us You must tell us everything that you know, or should know, could affect our decision to insure you and/or the terms on which we insure you. You must do this when you apply for a policy, renew your policy, and when you change or reinstate your policy. When we ask you specific questions, you must answer these questions truthfully and in a way that a reasonable person in the circumstances would answer them. It is important that every person who will be insured by the policy answers all questions in this way. These requirements are part of the Insurance Contracts Act What you do NOT need to tell us You do not need to tell us anything that: u reduces our risk. u is of common knowledge. u we know, or as an insurer should already know. u we tell you that we do not want to know. What will happen if you do not tell us If you withhold relevant information or you do not answer our questions in the way we have described, we can reduce the amount we pay for your claim, or we can cancel your policy. If your failure to tell us is fraudulent, or your answers are untruthful, we can treat your policy as if it never existed. When you are insured Your insurance begins when we accept your application. The commencement date of your insurance will be shown on the schedule that we will send you. The insurance applies for the period for which you have paid us (or agreed to pay us) the premium. You may pay your premium by cash, cheque or credit card. If your cheque or credit card is dishonoured by your financial institution, you are not insured. If you qualify, you can also pay your premium by instalments direct from a financial institution account or from your credit card. You cannot make a claim under this policy if you owed us more than one month s premium when the event about which you want to claim happened. If you pay your premium by instalments and you are more than one month behind, we can cancel your policy without notice. If you have a total loss, we may deduct the instalments for the balance of the period of insurance from the amount we pay you. Description of Cover Options Comprehensive Loss or damage to the insured vehicle up to its market value or sum insured whichever is the lower, and liability for damages arising from damage to other persons property up to the Limit of Indemnity, including legal costs. Fire, Theft and Third arty Loss or damage by fire or theft only to the insured vehicle up to its market value or sum insured whichever is the lower, and liability for damages arising from damage to other persons property up to the Limit of Indemnity, including legal costs. Third arty Only Liability for damages arising from damage to other persons property up to the Limit of Indemnity, including legal costs. When complete, please forward this application to: CGU Insurance, GO Box 9902 in the capital city of your state or your insurance adviser or your local CGU Insurance office.

3 CGU Insurance Limited ABN Commercial Motor Vehicle Insurance Application lease answer all questions. This will help us to process your application quickly. If you need more space to answer any of the questions, please use a separate sheet of paper. Any attachments will form part of this application and the declaration will include them. eriod of Insurance From Account no. Applicant(s) details To 4.00 p.m. on Agent or Broker olicy no. 2 : 4 : C : LOB = MVC : N : This Application replaces Cover te. Acceptance Names (include Trading As if applicable) Telephone ( ) rivate Bus. ostal address ostcode Business or occupation Details of All Regular Drivers Full name of regular drivers Date of birth Date licence obtained Expiry date of licence Occupation Approx. km driven per yr. Office Use Only REM LD : SEC : IN IN IN 100 2

4 Vehicles to be Insured (if insufficient space pl Veh. no. Registration or Serial Number Year of mnfr. RG RD Vehicle make and model, (include badge, body type - e.g. Holden Commodore SL sedan etc.) Engine size (litres) Carrying capacity (max. payload) of goods carrying vehicle Gross Vehicle Mass (tare plus max. payload) of goods carrying vehicle Current odometer reading Date of birth of usual driver Date of purchase Trailer (include no. of axles) Length (metres) Interested arties Is any other party(s) financially interested in any of the vehicles to be insured? If, state: Reg. or Serial no. Name of interested party Address ostcode Type of interest If space is insufficient attach a list in the same format as above. Limit of Indemnity Select LIMIT OF INDEMNITY for liability by ticking appropriate box: (Limit applicable to all vehicles) 20,000,000 Other (specify)

5 ease attach a list in the same format as below) urchase price Vehicles subject to finance (as detailed under Interested arties, below) roposed Sum Insured including accessories Comprehensive 562 Cover* Fire Theft and Third arty Third arty only Excess Where available, do you wish to pay extra to remove the standard excess? (Additional Excesses will still apply.) remium Goods and Services Tax Stamp Duty TOTAL *Only Comprehensive Cover is available for a trailer roposed Sum Insured for tarpaulins, gates and chains: AMOUNT AYABLE Office Use Only Veh.. 1 UNIT M/ CLASS : D C R YR YR REG. NUMBER T A N BI MA G VM VEH SN MAK OR RG : VOL. EXCESS : COM. EXCESS T S D EXOSURE 2 Veh UNIT : M/ CLASS D C R YR YR REG. NUMBER T A N BI MA G VM VEH VOL. EXCESS : SN : MAK OR RG : : : : COM. EXCESS T S D EXOSURE Questionnaire All questions must be answered by each of the Applicants and not by the agent or broker. If insufficient space, please provide additional details on a separate page. USE OF VEHICLES lease tick ( ) or and give details as requested. 1. Will the vehicles be used for purposes other than for private transport or in connection with the Applicant s business or occupation as stated in the Applicant panel on the first page? If, state the other uses 2. Will the vehicles be used to carry passengers for payment? lease turn over for further questions

6 lease tick ( ) or and give details as requested. 3. Will the vehicles be used to carry liquid fuel, toxic chemicals, organic peroxides, explosives or any corrosive, infectious or radioactive substance? If, a) Are there any drivers not licensed to drive in accordance with relevant regulations applicable for the carriage of such goods? b) Describe the method of carrying (e.g. drums, containers, etc.). c) State the usual type and quantity carried. 4. Will the vehicles be hired out to other operators? If, attach copies of hiring agreements. 5. From which base will the vehicles operate? 6. What is the normal area of operation of the vehicles? (If within a State, answer in kilometres) 7. Are your trailers ever coupled with other trailers and used as a Road Train, B-double etc.? 8. Do your vehicles have Australian compliance plates and do they comply with Australian design rules regarding safety and emission control? If to any part of the question, give details of the variations. 9. Are all your vehicles maintained in a roadworthy condition, in working order, free from mechanical defects and in an undamaged condition? If to any part of the question, give details. 10. Have any of your vehicles been modified or converted from the maker s specifications or fitted with accessories (costing more than 500 per item when new) other than those supplied as the maker s options? If, state: Reg. or serial no. DRIVING AND INSURANCE HISTORY 11. Have you, or any person who will drive any of your vehicles, Been charged with, or convicted of, or penalised for, any motoring offences in the last 5 years? This includes on the spot fines but does not include parking offences. Had a driving licence suspended, cancelled or restricted by endorsement in the last 5 years? If, complete details below. Full name of person Details of modification, alteration, adaptation or fitting Date of offence Nature of offence or endorsement Date of conversion Blood alcohol % reading Value of fittings enalty, fine or bond imposed

7 lease tick ( ) or and give details as requested. 12. Have you, or any person who will drive any of your vehicles, been charged with, or convicted of, any criminal offences in the past 10 years? If, complete the details below. Full name of person Date of offence Details of the charge, conviction, prosecution, penalty, fine or bond imposed 13. Have you, or any person who will drive any of your vehicles, had insurance cover cancelled or refused or had any special terms imposed by an insurer? (lease read the inside cover of this application before you answer this question.) If, complete details below. Full name of person Name of insurance company Action taken by insurance company Date of offence 14. Have you, or any person who will drive any of your vehicles, been involved in a motor vehicle accident, had a vehicle burnt or stolen, or claimed against an insurance company for damage to a vehicle, in the past 5 years? If, complete details below. Full name of person Date of occurrence Brief details (e.g. hit other vehicle in rear) Reg. no. of own vehicle Own damage Other damage Own insurance company s name Was a claim submitted to the insurance company? Full name of person Reg. no. of own vehicle Date of occurrence Brief details (e.g. hit other vehicle in rear) Own damage Other damage Own insurance company s name Was a claim submitted to the insurance company? 15. a) Name of previous insurer olicy number b) Do you currently have a Claims Bonus entitlement for any vehicle for which you are now applying for Comprehensive cover? If, attach the previous insurer s expiry or renewal notice. c) If the previous insurer s notice is for a different vehicle, do you still own that vehicle? DISCLOSURE AND DECLARATION 16. Are there any exceptional circumstances relating to the risk to be insured that you have not already told us about, and that you know or should know may affect our decision to insure you? If, please provide details on a separate page and attach to this application. 17. I/We declare that: a) the information in this application is true and correct and I/we have not withheld any relevant information. b) I/we agree to accept the insurance subject to the terms, conditions, exclusions and limitations of the policy. I/We authorise CGU Insurance to obtain or supply details of insurance claims and other relevant information. I/We authorise CGU Insurance to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. If you do not wish to receive any marketing material directly from us (such as special offers and discounts) tick this box. Signature of the Applicant Date Signature of the Applicant Date lease indicate the number of additional pages attached to this application

8 contact details New South Wales and ACT 388 George Street Sydney NSW 2000 t (02) f (02) Corporate Reception t (02) f (02) Victoria 485 La Trobe Street Melbourne VIC 3000 t (03) f (03) Queensland 189 Grey Street South Bank QLD 4101 t (07) f (07) Website: South Australia and NT 80 Flinders Street Adelaide SA 5000 t (08) f (08) Tasmania 188 Collins Street Hobart TAS 7000 t (03) f (03) Western Australia 46 Colin Street West erth WA 6005 t (08) f (08) Insurer CGU Insurance Limited ABN C0001 REV8 3/08