Diyadio WebForms :: Webform

PROPOSAL FORM FOR PRIVATE CAR INSURANCE

No risk attaches until the proposal has been accepted by the company and premium is paid or agreed to be paid

Your Details

Full name:

Your address:

Occupation:

Address:

Telephone:

Work

Home

Mobile

Interested Bank/Finance Company:

YOUR DUTY OF DISCLOSURE

You must tell us everything you know (or could be reasonably expected to know) that a prudent insurer would want to take into account in deciding:

Examples of what you must tell us include:

You must also tell us this every time this policy renews, and when you make any changes to it.
If you fail to do this, we may avoid the policy back to when it started as if you were never insured at all.
When in doubt, disclose. We treat all information confidentially.

YOUR PRIVACY

We collect and receive your personal information in this proposal to decide whether to insure you. We hold it in our records.

You have rights to access it, and correct it under the Privacy Act 1993. You must supply your personal information to us if it comes within your duty of disclosure (see Your Duty of Disclosure above).

If you fail to do so, we may decline your proposal or avoid your insurance retrospectively. We obtain your authority below to transfer some or all of it to other members of the insurance industry, financially interested parties noted on your policy and Insurance Claims Register Limited.

YOUR PREVIOUS HISTORY

Has any insurer ever refused to insure you on standard terms, or refused to renew your insurance on standard terms?

Yes

Has any insurer ever refused to pay your insurance claim?

Yes

Have you made any insurance claim in the last five years? (If yes, please explain in detail)

Yes

If yes, please explain in detail:

Do you know of any circumstances that could lead to a claim under any of our policies in the future?

Yes

Do you have any criminal convictions (including traffic offences, but not parking offences), or are you currently facing a prosecution? If yes, please list each offence or prosecution, and each sentence you received.

Yes

What type of Cover do you require

Full Cover” name=

Third Party Fire & Theft

Third Party Only” name=

Please list details of car(s)/vehicle, caravan/motorcycle/trailer/other.

Year	Make	Model	Engine Size and type	Registration Number	Market Value

Has any car been modified from the manufacturer's standard specifications? If so, please provide full details below. (Please list car accessories in excess of $1000.)

Who will drive your car?	Name	Sex	DOB	Type of Driving License
Main driver
1st additional driver
2nd additional driver

Do you want to exclude drivers under 25 for a premium discount?

Yes

Does the main driver own the vehicle?

Yes

YOUR DECLARATION

I declare that I:1

1 Have answered all questions truthfully.

2 Have, in addition, disclosed all material facts to New India (please see Your Duty of Disclosure above)

3 Agree to the policy terms and conditions.

4 Authorize:

4.1 New India to advise me of its other services from time to time

4.2 The disclosure of my personal information held by New India to:

4.2.1 Other members of the insurance industry, and

4.2.2 Financially interested parties noted on the policy, and

4.2.3 Insurance Claims Register Limited.

4.3 The disclosure of my personal information held by:

4.3.1 Other members of the insurance industry, and

4.3.2 Insurance Claims Register Limited to New India for the purpose of considering this proposal and administering the policy

5 Am authorized by everyone else to be insured under the policy to complete this proposal on their behalf, and they give the same declarations above. Signature of Proposer