MOTORCYCLE INSURANCE QUESTIONNAIRE

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1 MOTORCYCLE INSURANCE QUESTIONNAIRE Contact Details Contact Person Postal Address Phone Number Company Name (if applicable) Postcode Address Cover Type Comprehensive Agreed Value Third Party, Fire & Theft Comprehensive Market Value Third Party Only Current Insurance Details Current Insurer: Policy Expiry Date Rating / NCB: Is Claim Bonus Protection required? Insured & Driver Details Insured Name(s): Should be same as Reg. Owner How many years riding experience? Type of Motorcycle license Are you the registered owner? Retired / Pensioner? Driver Name Occupation D.O.B. Yrs Licenced % of use If any of the listed drivers have had Accidents / Claims or Traffic / Criminal Convictions in the last years detail below

2 MOTORCYCLE DETAILS Year: Make: Model: Style: Cyl: Eng Capacity: Reg / Vin : Modifications: Accessories: Use: Private Business Is the motorcycle under finance? Purch Date: Daily Twice per week Twice per month Value / Purch Price incl Access: Garage P/Code: If you have answered, please give details: Does the motorcycle have existing body damage or mechanical problems? If you have answered, please give details: Are you a member of a motorcycle club? If you have answered, please give details: Is the motorcycle an import not normally sold in this country If you have answered, please give details: SECURITY DETAILS At night, where is the motorcycle kept: Where is the motorcycle parked during the day? Does the motorcycle have: Garaged Car Port Driveway Street Alarm Immobiliser only 24hr Tracking Micro dotting Make of any alarm/anti theft device fitted if not standard: POLICY OPTIONS Is Excess Free Windscreen Cover required? Is Car Rental following an accident required? Is Claim Bonus Protection required? Is Additional Voluntary Excess required? Do you want to restrict the drivers or driver age limit to reduce premium? If you travel 10,000kms per year or less, do you want a Low Kilometre Policy to reduce premium?

3 GENERAL QUESTIONS Have any of the riders in the last year a. had their licence (motorcycle or motor vehicle) suspended, disqualified or cancelled? b. had an alcohol or drug related or driving conviction, infringement or offence? c. refused to take a breath test or breath analysis? If you have answered to any of the above, please give details: Have any of the riders in the last years been charged or summonsed for? a. riding or driving while unlicensed, suspended, disqualified, or cancelled? b. dangerous, reckless or careless riding or driving? c. had any other traffic, riding or driving conviction, infringement or offence (including on the spot fines)? If you have answered to any of the above, please give details: Have any of the riders in the last five years, whether insured or not, had a motorcycle or motor vehicle: a. accident at fault or not? b. stolen or burnt? c. claim against an insurance company? If you have answered to any of the above, please give details: Have any of the riders in the last 10 years been convicted or charged for: a. theft of a motorcycle or motor vehicle? b. arson? c. burglary? d. fraud e. a criminal offence of any kind? If you have answered to any of the above, please give details: Have you or any person likely to ride your motorcycle ever had an insurer for any class of motor insurance: a. cancel a policy b. decline or refuse cover c. decline to renew a policy or d. refuse to pay a claim? If you have answered to any of the above, please give details: Are there any circumstances which may be relevant to an Insurer s decision to insure you?

4 IMPORTANT FACTS The Purpose of this Questionnaire is to set out all relevant information for your adviser to submit on your behalf to the insurer(s). Under the Insurance Contracts Act 1984, you are under a duty to make full disclosure as follows: Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contract Act 1984 to disclose to the insurer every matter that you know or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matters that diminish the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows, or in the ordinary course of their business, ought to know; as to which compliance with your duty is waived by the insurer. n-disclosure If you fail to comply with your duty of disclosure the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the opportunity of voiding the contract from its beginning. There are other matters of which you should be aware in relation to the proposed professional indemnity insurance, as follows: Utmost Good Faith A contract of insurance is based on the utmost good faith requiring the insurers and the insured to act towards each other with utmost good faith in respect of any matter arising in relation to the insurance. Privacy We are committed to protecting your privacy. To provide you with our services, which include negotiation and acquisition of insurance, we need to obtain certain information from you and pass it on to the third parties who are necessary to assist us in providing these services to you. These include insurers, accountants, lawyers and other advisers. We use the information you provide to advise about and assist with your insurance needs. We do not trade, rent or sell your information. For further information about our Privacy Policy, ask for a copy or visit our website DECLARATION I/We the undersigned duly authorised person(s) declare that: I am/we are authorised by each of the Proposers to sign this Questionnaire; the above statements are correct, true and complete; and no information material to this Questionnaire has been withheld; and I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure; and I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and I/we acknowledge that the Insurer relies on the information and representations in this Questionnaire and otherwise made by me/us in relation to this insurance. Signature Full Name Position Date

5 Return to Address: Suite 1.01, Level 1, 27 Belgrave Street, MANLY NSW 209 Fax:

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