Prestige Motor Questionnaire

Prestige Motor Questionnaire

If any questions, please contact us at 1300 067873
Your Duty of Disclosure

You must tell us

When answering our questions, you must be honest and you have a duty under law to tell us anything known to you, and which a reasonable person in the circumstances, would include in answer to the question. We will use the answers in deciding whether to insure you or anyone else to be insured under the policy, and on what terms.

Who needs to tell us

It is important you understand you are answering our questions in this way for yourself and anyone else who you want to be covered by the policy.

If you do not tell us

If you do not answer our questions in this way, even by mistake, we may refuse to pay a claim, or cancel the policy, or both. If you answer the questions fraudulently, we may refuse to pay a claim and treat the policy as never having existed.

Unusual Terms

The policy you are applying for contains what may be considered unusual terms. These are listed in the Product Disclosure Statement (PDS). We strongly recommend that you read the PDS and the entire Policy Wording to make yourself familiar with all the terms and conditions of the Policy.

All questions must be answered in full. If there is insufficient space to fully answer any question, please attach a separate sheet of paper. If you are unsure how to answer any questions, please contact your insurance adviser.
Period of Insurance: From

MonthDayYear
To:

MonthDayYear
1. Applicant Details
Full Name*
Email:*
Address*
Company Name*
Phone Number (Bus hours)*

Area CodePhone Number
Mailing Address for Notices (If different from Home Add)
How did you hear about NSURE?*
2. Registered Owner
Company Name / Surname
First Name
Phone Number (Bus hours)

Area CodePhone Number
3. Purchase Details
Purchase Date

MonthDayYear
Purchase Price
Purchased From

Cover Options: Please select the cover required.

	Yes	No
Full Cover (Comprehensive)
Storage/Restoration Cover Only (NO COVER when driven)
Legal Liability Only

8. No Claim Bonus
We will use this information to confirm your No Claim Bonus. You do not need to forward any documentary proof of your No Claim Bonus entitlement.
Your current No Claim Bonus entitlement
Or rating number
Years of accident/claim free motoring
We will use your accident free motoring period to grant you a discretionary No Claim Bonus.

9. Declaration by the Applicant
I/we declare that:

• The Duty of Disclosure statement incorporated in this application has been read and understood by me/us.

• All answers and statements made in this application are true, complete and correct and that no information has been withheld.

• I/we have read and understood the application and policy.

• I/we understand that the "Notes" in this application are for my/our assistance, but I/we must read the Product Disclosure Statement and Policy Wording for full details of all policy terms, conditions and exclusions.

• I/we acknowledge Dawes Underwriting Australia Pty Ltd t/as Dawes Motor Insurance may give to, and obtain from, other insurers and/or insurance/financial reference bureau, parts or service providers, personal information relating to this application and/or policy as well as insurance claims information obtained during the currency of this policy.

• I/we understand that all drivers must be declared, otherwise cover will not apply.

• I/we understand that if I/we have elected to reduce the premium payable for this policy due to a restricted use of the vehicle, I/we must comply with the usage restrictions or the vehicle will not be insured.

• The answers provided are true, complete & correct on behalf of all persons to be insured.

• I/we have received or downloaded from the internet the Financial Services Guide, Product Disclosure Statement and Policy Wording.

• Before completing this application form, I/we have read and understood the Financial Services Guide, Product Disclosure Statement and Policy Wording.
Signature

Clear
Date Signed

MonthDayYear
Should be Empty:

	Accessory Fitted	Item Value $
1.
2.
3.
4.
5.
6.

	Driver's Name	Yrs Licensed	License Class	Occupation	No Claim Bonus %	Date of Birth
1.
2.

	Driver's Name	Yrs Licensed	License Class	Occupation	No Claim Bonus %	Date of Birth
1.
2.
3.
4.
5.
6.

	Yes	No
1. had a conviction for any criminal offence?
2. been charged or convicted of arson, or any offence involving dishonesty e.g. fraud, theft, handling stolen goods etc?
3. had a drivers licence refused, cancelled, suspended, special conditions imposed or been disqualified from driving?
4. had any insurance declined or cancelled, been refused renewal of any insurance, or had
special terms, conditions or excess/es imposed?
5. been charged or convicted or fined for driving under the influence of alcohol or having a
blood alcohol level in excess of that allowed by law?
6. been charged or convicted for driving under the influence of drugs?
7. refused to undertake a breath or blood test?
8. had a vehicle burnt or stolen even if recovered?
9. been declared bankrupt?

Prestige Motor Questionnaire

1. Applicant Details

2. Registered Owner

3. Purchase Details

4. Information About the Vehicle

5. Security, Accessories, Condition

6. Parking Details

7. Driver's Details

8. No Claim Bonus

9. Declaration by the Applicant

	Yes	No
1. had a motor vehicle accident or loss or made a claim under a motor vehicle insurance policy (regardless of who was at fault)?
2. been convicted, charged, prosecuted or fined for any driving or motoring offence including but not limited to speeding, traffic infringements (other than parking offences) and camera detected offences?

	Yes	No
1. Do you or any of the Authorised Drivers listed, currently suffer from or have suffered from in the last 5 years, any physical or mental disability or medical condition which would affect your or their driving performance?
2. Are you or any of the Authorised Drivers listed, currently dependent on or have you or they been dependent on in the last 5 years, any drug or medication which could affect your or their driving performance?