APPLICANT’S DETAILSMotor VehiclePersonal AccidentPublic LiabilityMarine Transit or Goods in Transit InsuranceName *Date of BirthAgeAddressStatePostcodeContact NumberEmail Address *Business NameABNAre you registered for GST?YNCourier CompanyType of RunSet RunAd Hoc RunAre you an existing client of GSK Insurance?YNClient CodeCOMMERCIAL MOTOR VEHICLE INSURANCEVEHICLE DETAILSPLEASE NOTE PACKAGED DANGEROUS GOODS LIABILITY IS COVERED UP TO $1,000,000 BY DEFAULT UNDER THIS PACKAGE, HOWEVER, IF YOU NEED TO CARRY BULK DANGEROUS GOODS WHICH REQUIRES SPECIAL PERMIT OR PLACARDS, KINDLY ADVISE US AS THIS IS NOT COVERED UNDER THE POLICY AND NEEDS SPECIAL AUTHORISATION.COMPREHENSIVE MOTOR VEHICLE INSURANCETHIRD PARTY PROPERTY DAMAGE INSURANCEIs this a fully Electric Motor VehicleYesNoRegistered Owner of Motor VehicleYEAR, MAKE AND MODEL OF THE VEHICLEREGISTRATION NUMBERENGINE NUMBER/ VINESTIMATED VALUEGROSS VEHICLE. MASS (GVM)/AGGRNon-Standard Accessories and Value Of:FINANCE COMPANY/ INTERESTED PARTYMAIN DRIVER DETAILSNAME OF THE MAIN DRIVERDATE OF BIRTHAGESTATEPOSTCODECONTACT NUMBERHOW MANY YEARS’ EXPERIENCE HAVE YOU HAD AS A COURIER DRIVER?HOW MANY YEARS HAVE YOU HELD AN AUSTRALIAN DRIVER’S LICENSE?HAVE YOU, YOUR BUSINESS, OR ANY PERSON WHO WILL DRIVE YOUR VEHICLE IN THE LAST 5 YEARS:BEEN CONVICTED OR FINED FOR ANY CRIMINAL OFFENCE?YNBEEN INVOLVED IN ANY MOTOR VEHICLE ACCIDENTS OR CLAIMS?YNIF YES, PLEASE PROVIDE THE FOLLOWING DETAILS IN THE SPACE PROVIDED BELOW: DATE OF LOSS, EXCESS PAID, NAME OF INSURED COMPANY AT THE TIME OF CLAIM, BRIEF DESCRIPTION OF THE CLAIM AND WHO WAS AT FAULT.BEEN REFUSED INSURANCE OR HAD A POLICY CANCELLED?YNHAD A DRIVER’S LICENSE ENDORSED, CANCELLED OR SUSPENDED?YNDO YOU HAVE ANY PHYSICAL OR INFIRMITY WHICH WOULD AFFECT THE DRIVING OF A MOTOR VEHICLE?YNANY OTHER INFORMATION WHICH MAY AFFECT THE INSURERS’ DECISION TO ISSUE INSURANCE FOR YOU ON THIS VEHICLE?YNIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE ALL RELEVANT DETAILS BELOWSECONDARY DRIVER DETAILSNAME OF THE SECONDARY DRIVERDATE OF BIRTHAGESTATEPOSTCODECONTACT NUMBERHOW MANY YEARS’ EXPERIENCE HAVE YOU HAD AS A COURIER DRIVER?HOW MANY YEARS HAVE YOU HELD AN AUSTRALIAN DRIVER’S LICENSE?HAVE YOU, YOUR BUSINESS, OR ANY PERSON WHO WILL DRIVE YOUR VEHICLE IN THE LAST 5 YEARS:BEEN CONVICTED OR FINED FOR ANY CRIMINAL OFFENCE?YNBEEN INVOLVED IN ANY MOTOR VEHICLE ACCIDENTS OR CLAIMS?YNIF YES, PLEASE PROVIDE THE FOLLOWING DETAILS IN THE SPACE PROVIDED BELOW: DATE OF LOSS, EXCESS PAID, NAME OF INSURED COMPANY AT THE TIME OF CLAIM, BRIEF DESCRIPTION OF THE CLAIM AND WHO WAS AT FAULT.BEEN REFUSED INSURANCE OR HAD A POLICY CANCELLED?YNHAD A DRIVER’S LICENSE ENDORSED, CANCELLED OR SUSPENDED?YNDO YOU HAVE ANY PHYSICAL OR INFIRMITY WHICH WOULD AFFECT THE DRIVING OF A MOTOR VEHICLE?YNANY OTHER INFORMATION WHICH MAY AFFECT THE INSURERS’ DECISION TO ISSUE INSURANCE FOR YOU ON THIS VEHICLE?YNIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE ALL RELEVANT DETAILS BELOWPERSONAL ACCIDENT AND SICKNESS INSURANCEINSURED NAME (this section must be completed)DOBHEIGHTWEIGHT CAPITAL BENEFIT $50,000 WEEKLY ACCIDENT $500 WEEKLY SICKNESS $500 CAPITAL BENEFIT $50,000 WEEKLY ACCIDENT $500 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $75,000 WEEKLY ACCIDENT $750 WEEKLY SICKNESS $750 CAPITAL BENEFIT $75,000 WEEKLY ACCIDENT $750 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $100,000 WEEKLY ACCIDENT $1000 WEEKLY SICKNESS $1000 CAPITAL BENEFIT $100,000 WEEKLY ACCIDENT $1000 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $125,000 WEEKLY ACCIDENT $1250 WEEKLY SICKNESS $1250 CAPITAL BENEFIT $125,000 WEEKLY ACCIDENT $1250 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $150,000 WEEKLY ACCIDENT $1500 WEEKLY SICKNESS $1500 CAPITAL BENEFIT $150,000 WEEKLY ACCIDENT $1500 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $175,000 WEEKLY ACCIDENT $1750 WEEKLY SICKNESS $1750 CAPITAL BENEFIT $175,000 WEEKLY ACCIDENT $1750 WEEKLY SICKNESS NO COVER CAPITAL BENEFIT $200,000 WEEKLY ACCIDENT $2000 WEEKLY SICKNESS $2000 CAPITAL BENEFIT $200,000 WEEKLY ACCIDENT $2000 WEEKLY SICKNESS NO COVER INSURANCE AND MEDICAL HISTORYDO YOU NOW HAVE OR ARE YOU APPLYING FOR ANY OTHER PERSONAL ACCIDENT AND/OR SICKNESS INSURANCE?YNHAVE YOU EVER HAD ANY ACCIDENT, SICKNESS OF LIFE PROPOSAL DECLINED OR COVER UNDER ANY POLICY RATED UP, CANCELLED, RENEWAL REFUSED OR ANY SPECIAL CONDITIONS IMPOSED THEREON?YNHAVE YOU EVER CLAIMED FOR AN ACCIDENT OR SICKNESS BENEFIT UNDER ANY INSURANCE BENEFIT?YNHAVE YOU BEEN TREATED, HOSPITAL CONFINED OR UNDERGONE ANY BLOOD TESTS IN THE LAST 5 YEARS?YNHAVE YOU HAD ANY MEDICAL, SURGICAL OR OTHER ADVICE IN THE LAST 5 YEARS?YNDO YOU TAKE PART IN HAZARDOUS PURSUITS OR ACTIVITIES; I.E.: DIVING, PILOTING, MOTOR SPORTS, HANG GLIDING ETC.?YNHAVE YOU EVER SUFFERED FROM ANY OF THE FOLLOWING: DIABETES, GOITRE, EPILEPSY, HEART DISEASE, CHEST PAINS, HIGH BLOOD PRESSURE, NERVOUS OR MENTAL DISORDER, RHEUMATIC FEVER, VARICOSE VEINS, HAEMORRHOIDS, TUBERCULOSIS, ASTHMA OR RESPIRATORY DISEASE, BACK OR MUSCULAR PAINS, RHEUMATISM, HERNIA, CANCER, TUMOUR OR GROWTH OF ANY KIND, SUDDEN WEIGHT LOSS, DISEASE OF THE EYE, EAR OR STOMACH?YNDO YOU PLAY SPORT FOR WHICH YOU RECEIVE ANY REMUNERATION?YNIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE ALL RELEVANT DETAILS BELOW This policy does not cover any condition directly or indirectly consequent upon, attributed or accelerated by any pre-existing illness or injury for which you have received treatment , advice or taken prescribed medicines or drugs in the period before commence of cover. Please note in the event of a claim, the insurer will only pay up to 85% of your net weekly earnings or the nominated amount on your policy schedule (whichever is lesser). 14 days waiting period applicable to each claimable incident. PUBLIC LIABILITY INSURANCEINSURED NAME *DATE OF BIRTHDO YOU WORK AS OWNER DRIVER?YNDO YOU HAVE ANY DRIVERS WORKING FOR YOU?YNDOES YOUR DRIVER WORK FOR YOU AS AN EMPLOYEE OR A SUBCONTRACTOR?YNHAVE YOU BEEN INVOLVED IN A CLAIM FOR PUBLIC LIABILITY IN THE LAST 5 YEARS?YNIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE ALL RELEVANT DETAILS BELOWMARINE TRANSIT OR GOODS IN TRANSIT INSURANCEINSURED NAME *DATE OF BIRTHHAVE YOU BEEN INVOLVED IN A CLAIM FOR MARINE TRANSIT IN THE LAST 5 YEARS?YNIF YOU ANSWERED YES TO ANY OF THE ABOVE QUESTIONS, PLEASE PROVIDE ALL RELEVANT DETAILS BELOWDECLARATIONI hereby declare and warrant that the answers given are in every respect true and correct and that I have not withheld information within my knowledge likely to affect the decision of the company to my eligibility for insurance. I hereby agree that this proposal and declaration shall form the basis of the contract between the company’s policy subject to the terms and conditions to be contained therein. NOTE: I / We give consent to GSK Insurance Brokers to disclose details of my / our Insurance arrangements to the Courier Company I / we are contracted to.SIGNATURE OF THE APPLICANTStart signing your signature hereYour browser does not support e-Signature field.SIGNATURE OF THE DRIVERStart signing your signature hereYour browser does not support e-Signature field.COMMENCEMENT DATEPLEASE NOTE THAT THERE IS NO COVER UNTIL WE HAVE CONFIRMED ACCEPTANCE OF COVER TO YOU IN WRITING.Eligible contracts (private motor, strata, home, contents, travel, personal accident/disablement) If the insurer asks you questions that are relevant to their decision whether to insure you and on what terms, you are required to tell the insurer about anything you know and that a reasonable person in the circumstances would include in answering their questions. At renewal the insurer may give you a copy of anything you previously told them and ask you to advise them if that information has changed. If they do this, you must tell them about any change or tell them if there is no change. If you don't tell the insurer about a change, the insurer assumes there is no change to this information. This duty applies until the insurer agrees to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract. All other contracts 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 their decision to insure you and on what terms. You have this duty until they agree 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 they know or should know as an insurer; or they waive your duty to tell them about. If you do not tell the insurer something If you don't tell the insurer something you are required to tell them, they may cancel your insurance contract or reduce the amount they will pay you if you make a claim, or both. If your failure to tell them is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. NOTICE OF INTENTION TO USE ELECTRONIC DELIVERY So that we can save you time and paper and improve our services we will be providing your insurance documents electronically. We will deliver your insurance policies, Product Disclosure Statements and our Financial Services Guide and other disclosure documents by sending an email with PDF attachments or sending an email with a hyperlink to the email address you have provided to us. If you do not wish for us to communicate with you in this way or at any stage you no longer wish to receive documentation from us electronically or you require a hard copy of any documentation, please contact us by phone on 1300 220 212 or email us at courier@gskinsurance.com.au.Submit
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