Comprehensive Insurance Application

Questions: If you have any questions regarding this application , please call us on 1300 225 582 and we will happily assist you.

Your Details

Full Name *

Address Details *

Street address *

Suburb *

State *

Postcode *

Contact Number *

Email Address

Driver(s) Details

Given Name *

Surname *

Date of Birth *

Sex M/F *

% Use of Vehicle *

Year license obtained in Australia *

Car Details

Alarmed? *

Immobiliser? *

Garaged at night? *

Please provide details of any modifications from the manufacturers standard list for this car *

Drivers' History

In the last 5 years have you or any person likely to drive this car

1. Had:

a) A claim, accident or car stolen and/or burnt? *

YesNo

b) Insurance refused, declined or cancelled by an insurer or special conditions imposed? *

YesNo

c) A drivers / motorcycle license cancelled, suspended or endorsed? *

YesNo

2. Been convicted or charged with:

a) Drug use, driving under the influence or exceeding Prescribed Concentration of Alcohol? *

YesNo

b) Any driving offences or issued any speeding of traffic infringements? *

YesNo

c) Fraud, arson, theft or any other criminal act? *

YesNo

3. Suffered from any physical or mental disability

a) That may affect your ability to drive (excluding eyesight corrected by lenses) *

YesNo

4. Not held any car insurance in the past 12 months

? *

YesNo

If you have answered "Yes" to 1-3 of the above, please provide details below -

Name of Driver

Incident Date

Details of each incident

Your Insurer

Person at Fault

Claims Cost

If you have answered "Yes" to Question 4, please provide details below:

Declaration

In signing this form I acknowledge and understand the Terms & Conditions of the Comprehensive Motor Car Insurance Policy.

I also declare that I have:

received a copy of the Policy Document;
read the information concerning the duty of disclosure and other important notices;
answered every question fully & frankly;
either completed this proposal form personally, or if it has been completed by someone else,
I have checked that the questions have been fully and accurately answered.

Please be advised that the initial approval of this application is based on the information provided and that if additional information is required, you may contacted by Alliance Leasing.

PLEASE NOTE: This application and any quote given is subject to full assessment on all the information provided by the applicant and is indicative to full assessment by the Insurer. Any failure to provide the correct information may give the Insurer the right to deny any claim.

Signature *

Draw signature|Type signatureClear

Date *

Please read and retain

YOUR DUTY OF DISCLOSURE:

Before you enter into this insurance contract with the proposed Insurer, the Insurance Contracts Act 1984 requires you to provide information that they may need to enable them to decide whether and on what terms your proposal for insurance is acceptable and to calculate how much premium is required for your insurance.

You will be asked various questions when you apply for this policy. When you answer these questions, you must:

provide the proposed Insurer with honest and complete answers
tell the proposed Insurer everything you know; and
tell the proposed Insurer everything that a reasonable person in the circumstances could be expected to tell an Insurer

Your duty however does not require disclosure of matters –

that diminishes the risk to be undertaken by the proposed Insurer;
that is of common knowledge
that the proposed Insurer knows or, in the ordinary course of our business, ought to know;
that the proposed Insurer tells you they do not need to know

NON DISCLOSURE:

If you fail to comply with your duty of disclosure, your proposed Insurer may be entitled to reduce their liability under the policy in respect of a claim or may cancel the policy. If your non-disclosure is fraudulent, they may also have the option of avoiding the contract from its beginning. It is therefore vital that you enquire of all entities comprising the Insured, including senior staff, before completing the proposal form and before you sign any declaration confirming no change in the information disclosed.

YOUR ON-GOING DUTY OF DISCLOSURE:

You have the same duty to disclose any further matters to your proposed Insurer before you renew, extend, vary or reinstate a contract of insurance.

ADDITIONAL INFORMATION:

Should there not be enough room to provide your answers to the questions herein, please provide your response in a separate document attaching and forming part of this application for insurance

PRIVACY ACT 1988:

Alliance Leasing is committed to protecting your privacy and the confidentially and security of personal information provided by you to us. We are therefore bound by the National Privacy Principles and the Privacy Act 1988 (Cth).

Information we collect:

All the information that we ask for is required for us to effectively coordinate your vehicle insurance and to provide you with the benefits available to you as part of the Alliance Leasing service package.

Right of access:

You have the right to access any such information held by Alliance Leasing that relates to you and to collect any information that is inaccurate. If you object to us using the information as described you can advise us at any time in writing.

Permission: I give express permission to receive Product Disclosure Statements and/or other relevant documentation electronically.

General Advice Warning:

Whilst we may have collected risk information, your personal objectives, needs or financial situations were not taken into account when preparing this information. We recommend that you consider the suitability of this general advice, in respect of your objectives, financial situation and needs. Please consider the relevant PDS before making any decision to purchase this financial product.