PERSONAL ACCIDENT AND SICKNESS QUOTE FORM

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YOU HAVE A DUTY OF DISCLOSURE OBLIGATION* This field is required.Ok, so before we start we need to tell you some things... Yes, it's boring, but it’s important and we need to do this - it only takes a minute. YOUR DUTY OF DISCLOSURE Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. NOTE: You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that: • reduces the risk they insure you for; or • is common knowledge; or • the insurer knows, or should know; or • the insurer waives your duty to tell them about. IF YOU DO NOT TELL THE INSURER SOMETHING If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. DUTY TO NOT MAKE A MISREPRESENTATION NOTE: if you are applying for a new consumer insurance contract, renewing a consumer insurance contract or varying an existing consumer insurance contract, which is an insurance policy obtained wholly or predominately in relation to personal, domestic or household insurance purposes, you must answer the specific questions asked by the insurer truthfully and accurately. In answering those questions, you must tell the insurer all information that’s known to you and that a reasonable person would be expected to provide in answer to the questions. APPLYING FOR A NEW CONSUMER INSURANCE CONTRACT OR VARYING AN EXISTING CONSUMER INSURANCE CONTRACT. • You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). • Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. • Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. • Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. • If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. • If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.

I agree

I don’t agree

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When do you need your policy to start?* This field is required.We can't back date policy, but we can change the start date - so if you are not sure - choose today...we can sort this out later.

Date

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Are you...?* This field is required.

a Sole Trader or Contractor

an Employee

working Director

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You’re doing great! Please tell us your name?* This field is required.

First Name

Last Name

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What is your DOB?

if required

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What is your address?* This field is required.We need a street address, not a PO Box please? That's the next question.

Street

Suburb

State

Post Code

Country

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Do you have a postal address?Leave this blank if you don't have a separate postal address.

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What’s your phone number?* This field is required.This is kind of important - we need this one completed. We might need to call you.

Area Code

Phone Number

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What’s your email?* This field is required.So we can email you your quote....

example@example.com

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Please tell us what you do - your occupation?

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What's your annual income?* This field is required.This will be the income from your last tax return or what you expect to earn this year in total.

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Which covers do you want?* This field is required.

Accident - Work Hours only

Accident - 24/7 cover

Sickness and Accident - 24/7 cover

Agreed value $1000 /week income for Accident 24/7 cover

Agreed Value $1,200/week income for Accident 24/7 cover

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What waiting period do you want?

7 days

14 days

28 days

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Have you made any personal accident or sickness claims in the last 5 years?

No

Yes

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Ok, please tells us about your claim for accident and sickness?We need info on what happened, how long your claimed for & the cost of the claim please.

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Have you, in the past 5 years... been charged or convicted of a criminal offence, been prosecuted under any health and safety legislation (or similar) or been declared bankrupt or gone into liquidation or been refused insurance?

No

Yes

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We are going to need a few details and we might need to give you a call too.e.g.: Lets start with the year and brief details of what happened and the outcome.

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Do you want us to call you about any of the following policy types?No strings attached - we can have a look at your other policies for you and provide a quote or explain what you are acutally covered for...what have your got to lose? Pick as many you like...

My Ute / Truck / Car

Management Liability + Employment Liability Insurance

Equipment or Machinery Breakdown

Mobile or Heavy Machinery Insurance

Income Protection + Trauma Insurance

Contract Works + Material Damage Insurance

Home / Renters or Landlords Insurance

No, thanks...I'm good

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Perfect...you’re all done! Before you hit that submit button please let us know where you heard about us?

A Friend

Yellow Pages

Facebook

Local Google Search

Existing Client

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