Steadfast Extra Care and Steadfast Elite Care Home and Contents Insurance Application
Steadfast Extra Care and Steadfast Elite Care Home and Contents Insurance Application Form IMPORTANT NOTICES Product Disclosure Statement (PDS) This application is for Steadfast Extra Care or Steadfast Elite Care Home and Contents insurance. Please read the applicable PDS prior to completing this application form. The contract of insurance is arranged by SUA Agency Services Pty Ltd (ABN 15 096 726 895, AFSL 234437) (SUA) (formerly Calliden Agency Services Pty Ltd) who acts as agent on behalf of ACE Insurance Limited (ABN 23 001 642 020, AFSL 239687) (ACE), the insurer of this product. General Insurance Code of Practice We are a signatory to the General Insurance Code of Practice (the Code). The objectives of the Code are to establish high standards of service, promote confidence in the general insurance industry and improve relationships between insurers and their customers. Further information about the Code is available at www.codeofpractice.com.au and on request. Your Duty of Disclosure Before you enter into or renew an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984 (Cth). If we ask you questions that are relevant to our decision to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. We may give you a copy of anything you have previously told us and ask you to tell us if it has changed. If we do this, you must tell us about any change or tell us that there is no change. If you do not tell us about a change to something you have previously told us, you will be taken to have told us that there is no change. You have this duty until we agree to insure you or renew the contract. If you do not tell us something If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. Privacy Statement In this Privacy Notice the use of we, our or us means ACE Insurance Limited (ACE) and SUA Agency Services Pty Ltd (SUA) unless specified otherwise. We are committed to protecting your privacy. This document provides you with an overview of how we handle your personal information. ACE s Privacy Policy can be accessed on its website at www.acegroup.com/au and SUA s Privacy Policy can be accessed on its website at www.steadfastagencies.com.au Personal Information Handling Practices Collection, Use and Disclosure We collect your personal information (which may include sensitive information) when you are applying for, changing or renewing an insurance policy with us or when we are processing a claim in order to help us properly administrate your insurance proposal, policy or claim. Personal information may be obtained by us directly from you or via a third party such as your insurance intermediary or employer (e.g. in the case of a group insurance policy). When information is provided to us via a third party we use that information on the basis that you have consented or would reasonably expect us to collect your personal information in this way and we take reasonable steps to ensure that you have been made aware of how we handle your personal information. The primary purpose for our collection and use of your personal information is to enable us to provide insurance services to you. Sometimes, we may use your personal information for our marketing campaigns, in relation to new products, services or information that may be of interest to you. We may disclose the information we collect to third parties, including service providers engaged by us to carry out certain business activities on our behalf (such as assessors and call centres in Australia). In some circumstances, in order to provide our services to you, we may need to transfer personal information to other entities within the ACE Group of companies, (such as the regional head offices of ACE located in Singapore, UK or USA) or third parties with whom we, or those other ACE Group entities, have sub-contracted to provide a specific service for us and these may be outside of Australia. In particular, certain business process functions of ACE are performed by a dedicated servicing unit located in the Philippines. Please note that no personal information is disclosed by us to any overseas entity for marketing purposes. In all instances where personal information may be disclosed overseas, in addition to any local data privacy laws, we have measures in place to ensure that those parties hold and use that information in accordance with 1
the consent you have provided and in accordance with our obligations to you under the Privacy Act 1988 (Cth). Your Choices In dealing with us, you agree to us using and disclosing your personal information as set out in this statement and our Privacy Policy. This consent remains valid unless you alter or revoke it by giving written notice to our Privacy Officer. However, should you choose to withdraw your consent it is important for you to understand that this may mean we may not be able to provide you or your organisation with insurance or to respond to any claim. How to Contact Us If you would like a copy of your personal information, or to correct or update it, please contact ACE s customer relations team on 1800 815 675 or email CustomerService. AUNZ@acegroup.com or in the case of SUA contact the Privacy Officer at the details provided in its Privacy Policy at www.steadfastagencies.com.au If you have a complaint or would like more information about how we manage your personal information, please review ACE s Privacy Policy for more details or contact the Privacy Officer, ACE Insurance Limited, GPO Box 4907, Sydney NSW 2001, Tel: +61 2 9335 3200 or email Privacy. AU@acegroup.com or in the case of SUA contact the Privacy Officer at the details provided in its Privacy Policy at www.steadfastagencies.com.au Form Completion Please answer all questions. Please tick (3) appropriate boxes and provide details as requested. If there is not enough space provided to answer a question, please complete your answer on a separate sheet of paper and attach it to the application form. Type Of Cover Which type of cover have you chosen? Steadfast Extra Care Home and Contents Insurance policy (Defined Events) Applicant Details For each applicant, please complete a separate box. For third and subsequent, please enclose details on a separate sheet. Applicant 1 Title Steadfast Elite Care Home and Contents Insurance policy (Accidental Damage)* *(only available for owner occupied properties) Mr Mrs Miss Ms Dr Other Given Names Surname Occupation Date of Birth Telephone Work Telephone Home Preferred Contact Day Preferred Contact Time Email Address am/pm Applicant 2 Title Mr Mrs Miss Ms Dr Other Given Names Surname Occupation Date of Birth Telephone Work Telephone Home Preferred Contact Day Preferred Contact Time Email Address 2
Period of Insurance From 4 pm to 4 pm Do you have an existing policy or a cover note? No Yes If yes, existing policy or cover note number Date of Expiry Details Of Your Home What is the address of the home/contents you wish to insure? Suburb State Postcode What is your postal address for correspondence? (If same, write as above ) Suburb State Postcode Do you own the home? No Yes Does anyone have a mortgage over the home? No Yes 1st Mortgagee Name of com pa ny Address Suburb State Postcode 2nd Mortgagee Name of com pa ny Address Suburb State Postcode Who lives in the home? You as the own er(s) You, as the tenant(s) Family members The home is unoccupied Date when will be occupied The home is under construction Period of construction to Does the land area exceed 2 hectares (5 acres)? No If Yes What is the land area? Do you run any form of farming or business from your property? No Yes Is mains pressure town water connected? No Yes Are there any dams or lakes on the property? No Yes Do you keep any livestock or animals on your property? No Yes What type of home is it? House, villa or townhouse Holiday home Flat or unit Which floor/level is it located on? What is the size of your home? Number of square metres Number of square feet OR 3
What are the walls made of? Solid brick Timber Brick veneer Cement sheet Other Do the walls, roof or pipes of the building contain asbestos? No Yes Do you consider the structure to be sound and well maintained? No Yes What is the age of your home? years If your home is brick and over 80 years old or timber and over 50 years old, has it been totally re-wired within the last 25 years? No Yes Not sure If not totally re-wired, please attach an electrical contractor's certificate of safety, or cover will be declined. Does the building have a National Trust Classification? No Yes What protection is installed at your home? Double cylinder deadlocks on all external hinged doors and key operated patio bolts on any external sliding doors All windows key locked Bars/grilles on windows Local burglar alarm Back to base or monitored burglar alarm Other Section 1 Buildings Insurance Do you want to insure your buildings? No Go to Contents Insurance Yes Please calculate the value of your buildings below. Note: To be fully insured, it is essential your sum insured represents the full replacement value of your buildings. Your sum insured will automatically be adjusted each year. Your Renewal Invitation will show your increased cover. Size Cost Replacement Value x = Add costs for fences, gates, paving, inground pool, spa, sauna, garage, shed, external blinds etc. Total Buildings Replacement Value 4
Section 1 Contents Insurance Do you want to insure the contents of your home? No Go to Liability Insurance Yes If you insure your buildings with us and also insure your contents under the one policy, you will receive a 10% premium discount. Steadfast Extra Care and Steadfast Elite Care Home and Contents Insurance policies both cover you for the full cost of replacement (new for old) for most items. (a) Contents Contents includes your furniture, bedding, electrical appliances, entertainment equipment, crockery, books, clothing, personal effects and the contents of your garden shed and garage, please refer to the PDS. Please write the value of your Contents at the bottom of this page. Note: To be fully insured, it is es sen tial your sum insured represents the full re place ment value of your contents. Your sum insured will automatically be adjusted each year. Your Renewal Invitation will show your increased cover. (b) Specified Contents The policies limit the amount we pay for the following while at the site: jewellery, watches, gold or silver objects and collections up to 5,000 (Steadfast Extra Care Home and Contents Insurance policy) / 10,000 (Steadfast Elite Care Home and Contents Insurance policy) per item or set and up to 25% of the sum insured in total. If you have any of the items above and you wish to insure them for more than the item limits shown, you must list them below. You must also attach to this application a valuation not more than five years old or a receipt of purchase. Please list your Specified Items: (Goods that you use for earning your income cannot be covered as a specified item) Description/Make/Model Replacement Value (b) Value of Specified Items (a) Value of Contents Total Contents Replacement Value Section 1 Liability Insurance This section is automatically included and is free of charge with Buildings and/or Contents Insurance. This covers compensation for death or bodily injury or illness to any person or for loss or damage to property, subject to policy limitations and exclusions. The cover is 20 million for both Steadfast Extra Care and Steadfast Elite Care Home and Contents Insurance policies and includes: (a) Buildings Insurance, as the property owner; and/or (b) Contents Insurance, as an occupier of the home and for personal liability cover anywhere in the world. 5
Section 2 Valuable Items Insurance You may only select this option if you are insuring your Contents. Please see the PDS for the items covered. Valuable Items Insurance covers you for accidental loss or damage to the insured property anywhere in Australia and New Zealand. This cover extends worldwide for up to 90 days with Steadfast Extra Care Home and Contents Insurance policy, and worldwide for the duration of the policy with Steadfast Elite Care Home and Contents Insurance policy. There are two types of Valuable Items insurance. You may choose to take out both cover types. An excess applies to both cover types. (a) Unspecified Valuable Items (not applicable to Steadfast Elite Care Home and Contents Insurance policy) You do not need to list the items insured. Unspecified valuable items are covered for up to 5,000 each and in total up to the amount shown on your schedule. Do you require Unspecified Valuable Items Insurance? No Go to Section (b) Yes Total Unspecified Valuables Items Replacement Value (b) Specified Valuable Items If any item that you wish to cover exceeds the limit for Unspecified Valuable Items, then you may choose to insure it as Specified Valuable Items. You must nominate the sum insured for each item. You must also attach to this application a valuation not more than five years old or a receipt of purchase for items valued in excess of 5,000 for Steadfast Extra Care Home and Contents Insurance policy or 10,000 for Steadfast Elite Care Home and Contents Insurance policy. We also recommend that you supply a photograph of your valuable items to us for safe keep ing. Do you require Specified Valuable Items Insurance? No Yes Please list your Specified Valuable Items: Description/Make/Model Replacement Value Total Specified Valuable Items Replacement Value 6
Additional Questions All of the following questions must be answered. 1. Do you believe that the sums insured would adequately cover you for a total loss? No Please recalculate the sums insured. Yes 2. Have you, your spouse, partner or any other family member residing permanently with you, or if a corporation, any of its directors, proposed to be insured under this policy, either alone or jointly: (i) had any insurance declined, cancelled or refused renewal by an insurer, had any special condition/warranty imposed or been required to pay an increased premium or excess in the past 5 years? No Yes Please give details including name of insurer and relevant dates (ii) suffered any loss, destruction or damage and/or made a claim on any insurer for any event whether insured or otherwise in relation to home, home con tents, business, personal valuables or legal liability in the past 5 years? No Yes Please give details including name of insurer, amounts and relevant dates (iii) been convicted of a criminal offence, entered into a good behaviour bond or do you have any charge pending for any criminal offence/s in the past 5 years? No Yes Please give details including court and relevant dates (iv) been declared bankrupt in the past 5 years? No Yes Date 3. Has your home or the area within 250 metres of the home been affected by flooding in last 5 years? Or is the home within 250 metres of any government-gazetted or named natural water course? No Yes Please give details 4. Is your Home and/or Contents Insurance currently with another insurer? No Yes Name of Insurer Home Policy Number Name of Insurer Contents Expiry Date Policy Number Expiry Date 7
Excess An excess is the amount you have to pay if you make a claim. The standard excess is 300. Which excess do you choose? 300 500 1,000 The premium payable will depend on the excess you choose. The higher the excess, the lower your premium. Note: A compulsory excess of 50 applies to Valuable Items Insurance. On some Valuable Items a 100 excess applies. In addition to the standard excess, the following excesses apply: 200 additional excess for earthquake and an additional 2,000 excess applies for flood. Payment Details I/we wish to pay: (1) The full amount: cheque enclosed credit card* * A credit card payment processing fee applies (Visa/MasterCard 0.99% (incl GST)). Mastercard Card number Visa Expiry Date Amount Signature (2) By Direct Debit ( Please complete Direct Debit Request Form. An instalment fee may apply. Please refer to the PDS for further information) Declaration I/we declare that: The Duty of Disclosure and Privacy statement incorporated in this application have been read and understood by me/us. All answers and statements made in this application are true, complete and correct. I/we consent to SUA and ACE using the personal information (including sensitive information) I/we have provided on this form for the purposes of administering my/our insurance. I/we consent to the disclosure of personal information (including sensitive information) to third parties and overseas where it is reasonably necessary for the purposes of administering my/our insurance. I/we understand that if this consent is not given SUA and ACE will not be able to administer my/our insurance. I/we have received or downloaded from the internet the Financial Services Guide, Product Disclosure Statement and Policy Wording. I/we have read and understood the Financial Services Guide, Product Disclosure Statement and Policy Wording. Applicant 1 Signature Date Applicant 2 Signature Date Please check that you have answered all questions and return to: SUA Agency Services Pty Ltd Phone: 1300 00 2255 Fax: 1300 662 215 Address: Level 9, 11-33 Exhibition Street, Melbourne VIC 3000 Postal: GPO Box 3208, Melbourne VIC 3001 8
Office Use Only Policy Number Agency Number or Name Quote Number Section 1 Sum to be Insured Policy Premium Buildings Contents Sub Total A Plus Loadings % Sub Total B (Sub Total A x Total Loadings) + Sub Total A Less Discounts % Sub Total C Sub Total B (Sub Total B x Total Discounts) Plus or Less Excess Allowance Base Premium Sub Total C + or Excess Allowance Fire Services Levy GST (Applies to Base + FSL) Stamp Duty (Applies to Base + FSL + GST) Total Home & Contents Premium Base Premium + FSL + GST + Stamp Duty Agency Fee Agency Fee GST Total Due Valuable Items Premium Obtain rate, apply loadings & discounts as per the above sequence to arrive at base rate, then add GST and stamp duty for total. Valuable Items Add GST & stamp duty POLICY TOTAL Home + Contents + Valuable Items Signature of Underwriter Date 9
ACE Insurance Limited The ACE Building, 28 O Connell Street, Sydney NSW 2000 ABN 23 001 642 020 AFSL 239687 www.acegroup.com/au Product issued by ACE Insurance Limited ACE SF EXEL APP 1115