Contact details:

Telephone

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: whether to accept your proposal, and if so, on what terms.
Examples of what you must tell us include:

• Anything that increases the risk of a claim
• Any criminal offending or convictions
• Any previous insurance claims
• Any refusal by another insurer to insure you on standard terms, or continue to insure you on standard terms.

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.

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

The following questions must be answered in relation to the business, and in relation to every director and manager of the business

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

Has any insurer ever refused to pay your insurance claim?

Have you made any insurance claim in the last five years?

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

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 your business has received.

What type of cover do you require?

List the details of car(s)/truck, trailer/other

Year	Make	Chassis Number	Engine size and number	Registration Number & class of license required to operate	Market Value

Driver Details

Please complete in relation to all drivers

Name	Date of birth	Type of License	Years had license for class of vehicle	Percentage use of the vehicle

Please give details of any accidents or motor vehicle claims (whether your fault or not) during the last 3 years in connection with a motor vehicle owned or operated by you, or any person who will drive the vehicles:

Do you require insurance for an agricultural implement or machine?

Do you require a cover for hiring a substitute vehicle?

Do you require cover for liability for rental vehicles?

I declare that I:

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 other members of the insurance industry, financially interested parties noted on the policy and Insurance Claims Register Limited.
4.3 The disclosure of my personal information held by other members of the insurance industry and Insurance Claims Register Limited to New India for the purpose of considering this proposal and administering the policy. 5 Am authorized to complete this proposal on behalf of anyone else to be insured under the policy, and agree that they give the same declarations. Signature of Proposer