Farm. Farm Pack proposal. Important Notices. Please read this section before completing this proposal

Transcription

1 Farm Pack proposal Important Notices Farm Commercial Policy Number Please read this section before completing this proposal Your Duty of Disclosure: Before You enter into this insurance contract with Us for the first time, the Insurance Contracts Act 1984 requires You to provide Us with the information We need to enable Us to decide whether and on what terms Your proposal for insurance is acceptable and to calculate how much premium is required for Your insurance. You will be asked various questions when You apply for this policy. When You answer these questions, You must: give Us honest and complete answers; tell Us everything You know; and tell Us everything that a reasonable person in the circumstances could be expected to tell Us. You do not need to tell Us about any matter: that diminishes Our risk; that is of common knowledge; that We know or should know as an insurer; or that We tell You We do not need to know. Who does the duty apply to? Everyone who is insured under the policy must comply with the relevant duty. What happens if You or they breach the duty? If You or they do not comply with the relevant duty, We may cancel the policy or reduce the amount We pay if You make a claim. If fraud is involved, We may treat the policy as if it never existed and pay nothing. Duty on renewals, variations and reinstatements: A different duty applies for any variation or renewal or reinstatement of the policy. Please refer to Your policy document for this duty. Privacy Act 1988: The Privacy Act 1988 requires Us to tell You that as an insurer We collect Your personal and other information in order to: decide whether to issue a policy; determine the terms and conditions of Your policy; compile data; and handle claims. We disclose personal information to third parties who We deal with in providing Our services to You. For example, in handling claims, We may have to disclose Your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents or other parties as required by law. We limit the use and disclosure of any personal information provided by Us to them to the specific purpose for which We supplied it. You have the right to seek access to Your personal information and to correct it at any time. Please contact Us on , EST 9am-5pm, Monday-Friday and advise Us of any changes. If You do not agree to the collection of Your personal information then unfortunately We will be unable to process Your proposal. From time to time We may advise or offer You information on other Allianz products or services that may be relevant and of interest to You. If You do not wish to receive these offers or information please call the Allianz Direct Marketing Privacy Service Line Freecall , EST 9am-5pm, Monday-Friday. How to fill out this proposal: For questions with multiple choice answers, please tick the box in front of the correct answer. For other questions, please write the information requested in the spaces provided. Make sure You have read the policy document We have given to You. If You require another copy of the policy document or any assistance, please contact Your insurance broker or agent. If there is inadequate space to answer any questions, please attach a separate sheet of paper. Show the page number, section and question number before the information You wish to add, eg. Page 3, Personal Effects Specified Personal Effects (continued). Definitions: We, Our, Us or Allianz means Allianz Australia Insurance Limited AFS Licence No ABN You or Your means the person proposing for this insurance and any person seeking to be named on the Schedule. Excess means the amount You must pay towards the cost of any claim under Your policy. This proposal uses words that have a special meaning. The definition of these words can be found in the policy document. Underinsurance: The Farm Property and Machinery Breakdown Sections of this contract contain underinsurance clauses. It is important in these Sections that You insure the full value of the property and declare the total number of machines. If You do not do so, You will be underinsured and We will not pay Your claim in full. Limited always to the Sums Insured and subject to the precise policy wording, the amount of claim will be determined by the following formula: Sum Insured/ Amount of No of machines insured Damage x = Claim Payment X of Replacement value/ 1 Average income/ Total No of machines X = 80 Farm Property 100 Machinery Breakdown Flood: Property covered by this policy in Section One, Two and Eight is not insured against Flood damage. Excess: Excesses apply to all sections of Your Policy and are detailed in the Schedule and/or policy document. PRP009BA/FI 01/04 (Office Use Only) Date proposal received / / Time AM / PM Policy number Broker/agent Broker/agent account number Cover note number Replacing policy number State This Insurance is provided by Allianz Australia Insurance Limited AFS Licence No ABN Registered Office: 2 Market Street Sydney NSW 2000

2 Period of Insurance From am/pm on until 4pm on Proposer s general information Your name Mr/Mrs/Miss/Ms 3. Phone Home ( ) Mobile Business ( ) 4. Full postal address 5. Situation of farm 6. Type of farming (eg beef, cropping etc.) 7. Name and address of mortgagees (if applicable) Are You registered for GST? Yes No If Yes, please provide ABN What is Your ITC percentage? 1 Home Building and/or Contents Buildings incl. domestic outbuildings Building 1 (main) Building 2 Building 3 Building 4 Identification e.g. Homestead, Cottage etc. State whether: Home of proposer, tenanted or unoccupied of Building Area of Building (sqm) Year Building built If 45 yrs old or more, when was Building last rewired? External walls constructed of Brick Other Brick Other Brick Other Brick Other Do You have deadlocks and window locks? Yes No Yes No Yes No Yes No Is the Building in a good state of repair? Yes No Yes No Yes No Yes No Basis of settlement Replacement Indemnity Indemnity Indemnity (Buildings only.) Indemnity Replacement Replacement Replacement Building Sum Insured Contents Sum Insured If the Contents are to be insured, state total value of all: jewellery, watches, gold or silver articles worth more than 1,500 each, or documents, Collections or Sets of any kind, curios, pictures, paintings or other works of art, oriental rugs or carpets worth more than 5,000 each. Contents: The policy has the following limits applying to valuables of the type mentioned above: (i) for the total of these items, 20 of the Sum Insured on Contents; (ii) for each item, Set or Collection consisting of jewellery, watches or items containing gold and/or silver, 1,500; (iii) for Contents items consisting of documents, Collections, or Sets of any kind, curios, pictures, paintings or other works of art, oriental rugs or carpets, 5,000. If You wish to insure for more than the limits specified above, please list the items below. You will need to supply Us with proof of ownership and a current valuation at the time of a claim. Contained in Description Sum Insured Building no Page 2

3 Home Building and/or Contents (continued) Options Personal Effects (Available only when You have Contents cover). Accidental loss or damage to Your unspecified and/or specified personal effects in Australia or New Zealand or anywhere else in the world for a maximum of 35 days in any one Period of Insurance. Unspecified Personal Effects: Indicate cover required. 1,500 cover per item limit 500 2,000 cover per item limit 750 5,000 cover per item limit 750 7,500 cover per item limit 1,000 Specified Personal Effects: Give model and serial number for watches, cameras, etc. You will need to supply Us with proof of ownership and a current valuation at the time of a claim. Description Serial Number Sum Insured Domestic Workers Compensation (Note: This insurance is only available in NSW, ACT, TAS, WA) Do You require this insurance? Yes No Total Office Use Only Company premium 2 Farm Property Farm Building(s) and Farm Contents Select either replacement (R) or indemnity (I) cover Buildings Contents Description (eg. machinery shed) Year built External walls of Buildings Contents Sum Insured Sum Insured Brick Other R I R I Brick Other R I R I 3. Brick Other R I R I 4. Brick Other R I R I 5. Brick Other R I R I 6. Brick Other R I R I Total Fencing Wholly owned Fencing km at per km (100) Sum Insured Shared Fencing km at per km (50) Sum Insured Total Fencing means fencing, yards, ramps, troughs, feeders, power poles and accessories for which You are liable. If You are not insuring all Fencing, please attach a map to identify which Fencing is being insured. 3. Machinery and implements In the open air or in any Farm Building on the property Description (make, model and serial number) Year of manufacture Sum Insured Total 4. Livestock In the open air or in any Farm Building on the property Description (eg. cattle) Approx. number Approx. value per animal Sum Insured Note: The amount We will pay for Livestock will not exceed 5,000 for any one animal. Total Page 3

4 Farm Property (continued) 5. Other Is cover required? Sum Insured (a) Drought relief Livestock slaughtered due to drought Yes No (b) Removal of debris Removal of debris if Farm Property damaged Yes No (c) Additional costs Additional costs to maintain Farming Business following a loss Yes No (d) Wool Value of Wool anywhere in Australia until sold Yes No (e) Grain/Hay/fertiliser Value of Grain/Hay/fertiliser Yes No (f) Accidental Damage Yes No (Sum Insured for Accidental Damage) 15,000 25,000 50,000 Other (please specify) Office Use Only 3 Public and Products Liability (Provides liability cover for Your Farm Business) Situations to be covered Company premium 3. Limit of Indemnity required 5 million 10 million 20 million Other (please specify) 3. Size of farm ha ha More than 5001 ha Hobby Farm (Area less than 50 ha and turnover less than 15,000) 4. Type of farm Livestock production Non-livestock production Mixed farming (combination of livestock and non-livestock production) If farming activity involves Livestock production, how would You rate the condition of boundary Fencing on the property? Excellent Good Fair Poor 5. Do You undertake any contract work? Yes No If Yes, please provide details Type of contract work Percentage of turnover in a typical year 6. Do You employ contractors where labour costs exceed 100,000? Yes No 7. (a) Do You provide any holiday farm accommodation Yes No If Yes, turnover in a typical year Number of rooms (b) Do You offer horse riding activities to paying guests Yes No If Yes, number of horses An Excess of 500 applies to Property Damage claims. Office Use Only Company premium Page 4

5 4.1 Motor Vehicles Domestic Motor Domestic Motor covers passenger vehicles. Vehicle 1 Type of cover required Please tick one box only to indicate the type of insurance You require. (a) Comprehensive (Market Value) (b) Third party property damage only (c) *Third party property damage, fire and theft Enter value required (maximum 5,000). Options for comprehensive insurance only *Increase basic Excess by *Removal of basic Excess for windscreen claims. Protected no claim bonus only available if You have a full no claim bonus. * Not available in all States. Your insurance provider will advise You what covers are available. 3. Make/Model Make e.g. Ford Month and year of manufacture Model and series e.g. Falcon GLi 4. Vehicle Registration (a) Registration number (b) In whose name is the vehicle registered? (c) Engine serial number 5. Type of body (e.g. sedan/ute): Date of registration 6. Current no claim bonus Previous insurer Policy number Expiry date 7. Does anyone have a financial interest in Your Vehicle? Yes No If Yes, (a) Please indicate type of financial arrangement: Personal loan Lease Bill of sale Finance Other (please specify) (b) Name and address of finance provider 8. Vehicle purchase Purchase date Purchase price 9. Garage location of vehicle 10. If there have been any modifications or if Your Vehicle has any accessories which are not standard or supplied by the manufacturer, please provide details below. Nature of modification/accessory Description (e.g. make, model, etc.) Current Value 1 Does Your Vehicle have any security devices fitted? Yes No If Yes, description 1 Does Your Vehicle have any existing damage? Yes No If Yes please describe damage 13. Regular driver details. It is important that You list the names of everyone (including You) who will drive Your Vehicle more than 12 times a year. If during the currency of the policy, any person under 25 years of age becomes a regular driver of Your Vehicle You should inform Us immediately. Number of years Estimated Does driver Gender fully licensed in of total use by own their Drivers names M/F Date of birth Australia each driver own vehicle Page 5

6 4.1 Motor Vehicles Domestic Motor (continued) Domestic Motor covers passenger vehicles. Vehicle 2 Type of cover required Please tick one box only to indicate the type of insurance You require. (a) Comprehensive (Market Value) (b) Third party property damage only (c) *Third party property damage, fire and theft Enter value required (maximum 5,000). Options for comprehensive insurance only *Increase basic Excess by *Removal of basic Excess for windscreen claims. Protected no claim bonus only available if You have a full no claim bonus. * Not available in all States. Your insurance provider will advise You what covers are available. 3. Make/Model Make e.g. Ford Month and year of manufacture Model and series e.g. Falcon GLi 4. Vehicle Registration (a) Registration number (b) In whose name is the vehicle registered? (c) Engine serial number 5. Type of body (e.g. sedan/ute): Date of registration 6. Current no claim bonus Previous insurer Policy number Expiry date 7. Does anyone have a financial interest in Your Vehicle? Yes No If Yes, (a) Please indicate type of financial arrangement: Personal loan Lease Bill of sale Finance Other (please specify) (b) Name and address of finance provider 8. Vehicle purchase Purchase date Purchase price 9. Garage location of vehicle 10. If there have been any modifications or if Your Vehicle has any accessories which are not standard or supplied by the manufacturer, please provide details below. Nature of modification/accessory Description (e.g. make, model, etc.) Current Value 1 Does Your Vehicle have any security devices fitted? Yes No If Yes, description 1 Does Your Vehicle have any existing damage? Yes No If Yes please describe damage 13. Regular driver details. It is important that You list the names of everyone (including You) who will drive Your Vehicle more than 12 times a year. If during the currency of the policy, any person under 25 years of age becomes a regular driver of Your Vehicle You should inform Us immediately. Number of years Estimated Does driver Gender fully licensed in of total use by own their Drivers names M/F Date of birth Australia each driver own vehicle Page 6

7 4.1 Motor Vehicles Domestic Motor (continued) Domestic Motor covers passenger vehicles. Vehicle 3 Type of cover required Please tick one box only to indicate the type of insurance You require. (a) Comprehensive (Market Value) (b) Third party property damage only (c) *Third party property damage, fire and theft Enter value required (maximum 5,000). Options for comprehensive insurance only *Increase basic Excess by *Removal of basic Excess for windscreen claims. Protected no claim bonus only available if You have a full no claim bonus. * Not available in all States. Your insurance provider will advise You what covers are available. 3. Make/Model Make e.g. Ford Month and year of manufacture Model and series e.g. Falcon GLi 4. Vehicle Registration (a) Registration number (b) In whose name is the vehicle registered? (c) Engine serial number 5. Type of body (e.g. sedan/ute): Date of registration 6. Current no claim bonus Previous insurer Policy number Expiry date 7. Does anyone have a financial interest in Your Vehicle? Yes No If Yes, (a) Please indicate type of financial arrangement: Personal loan Lease Bill of sale Finance Other (please specify) (b) Name and address of finance provider 8. Vehicle purchase Purchase date Purchase price 9. Garage location of vehicle 10. If there have been any modifications or if Your Vehicle has any accessories which are not standard or supplied by the manufacturer, please provide details below. Nature of modification/accessory Description (e.g. make, model, etc.) Current Value 1 Does Your Vehicle have any security devices fitted? Yes No If Yes, description 1 Does Your Vehicle have any existing damage? Yes No If Yes please describe damage 13. Regular driver details. It is important that You list the names of everyone (including You) who will drive Your Vehicle more than 12 times a year. If during the currency of the policy, any person under 25 years of age becomes a regular driver of Your Vehicle You should inform Us immediately. Number of years Estimated Does driver Gender fully licensed in of total use by own their Drivers names M/F Date of birth Australia each driver own vehicle Page 7

8 4.1 Motor Vehicles Domestic Motor (continued) Domestic Motor covers passenger vehicles. Vehicle 4 Type of cover required Please tick one box only to indicate the type of insurance You require. (a) Comprehensive (Market Value) (b) Third party property damage only (c) *Third party property damage, fire and theft Enter value required (maximum 5,000). Options for comprehensive insurance only *Increase basic Excess by *Removal of basic Excess for windscreen claims. Protected no claim bonus only available if You have a full no claim bonus. * Not available in all States. Your insurance provider will advise You what covers are available. 3. Make/Model Make e.g. Ford Month and year of manufacture Model and series e.g. Falcon GLi 4. Vehicle Registration (a) Registration number (b) In whose name is the vehicle registered? (c) Engine serial number 5. Type of body (e.g. sedan/ute): Date of registration 6. Current no claim bonus Previous insurer Policy number Expiry date 7. Does anyone have a financial interest in Your Vehicle? Yes No If Yes, (a) Please indicate type of financial arrangement: Personal loan Lease Bill of sale Finance Other (please specify) (b) Name and address of finance provider 8. Vehicle purchase Purchase date Purchase price 9. Garage location of vehicle 10. If there have been any modifications or if Your Vehicle has any accessories which are not standard or supplied by the manufacturer, please provide details below. Nature of modification/accessory Description (e.g. make, model, etc.) Current Value 1 Does Your Vehicle have any security devices fitted? Yes No If Yes, description 1 Does Your Vehicle have any existing damage? Yes No If Yes please describe damage 13. Regular driver details. It is important that You list the names of everyone (including You) who will drive Your Vehicle more than 12 times a year. If during the currency of the policy, any person under 25 years of age becomes a regular driver of Your Vehicle You should inform Us immediately. Number of years Estimated Does driver Gender fully licensed in of total use by own their Drivers names M/F Date of birth Australia each driver own vehicle Page 8

9 4.2 Motor Vehicles Commercial Motor Commercial Motor covers non-passenger vehicles, e.g. tractors/harvesters Year No Claim Made Vehicle Description (e.g. John Deere 9750sts) Type of Cover* Operating Radius Bonus Sum Insured km km 3. km 4. km 5. km 6. km 7. km 8. km 9. km 10. km * Choose from Comprehensive (COMP), Third party property damage (TPPD) or Third Party Property Damage, Fire and Theft (TPFT) Are all vehicles serviced regularly and maintained in sound working order? Yes No Do any of the above vehicles have any non-standard modifications or accessories? Yes No If Yes, please provide details 3. Are any of the above vehicles used for: (a) Contract cartage Yes No (d) Hire or loan to any drivers other than those (b) Contract harvesting Yes No within Your direct employ or family? Yes No (c) Other non-farm work Yes No (e) The transport of hazardous goods? Yes* No If You have answered Yes to any of the above questions, please provide details: * If You have answered Yes to the transport of hazardous goods, please provide confirmation that all goods are transported in accordance with all relevant legislation. Office Use Only Company premium 5 Personal Accident and Sickness Indicate cover and Benefit Period required (a) Cover: Accident Only Accident and Sickness Capital, Accident and Sickness (b) Benefit Period: 26 weeks 52 weeks 104 weeks Specify Sums Insured Required: Capital Benefit Weekly Benefits: Accident per week Sickness per week Excess A standard Excess of 14 days applies to this Section. For a premium reduction do You wish to increase the Excess Period? Yes No If Yes, please select an Excess Period 21 days 28 days Note: Sickness cover commences 28 days after We accept Your proposal. Page 9

10 Personal Accident and Sickness (continued) 3. Insured Persons Person 1 Person 2 (a) Full names of people to be insured (b) Date of Birth* (c) Height (d) Weight cm kg cm kg * To be eligible for cover, the Insured Person must be aged between 16 years and 55 years. (e) Tick the box(es) which most accurately Home duties including minor farm labour Home duties including minor farm labour describe the Insured Person s Occupation Farm owner/manager Farm owner/manager Full-time manual labour Full-time manual labour 4. Details of Insured Person(s): (a) Does the Insured Person have or have they ever suffered from: (i) high or low blood pressure, cancer, tuberculosis, diabetes, ulcers, paralysis, arthritis or rheumatism, AIDS or an AIDS related condition, or Yes No Yes No (ii) any disorders of the mental, respiratory, nervous, genito-urinary digestive or circulatory systems, or heart, liver, spine, eyes or back, or Yes No Yes No (iii) any physical impairment or deformity, or Yes No Yes No (iv) any other sickness or injury not listed? Yes No Yes No (b) Does the Insured Person engage in or are they intending to engage in any of the following: Aviation or ballooning (other than as a fare paying passenger), boxing, bungy-jumping, canoeing, diving (underwater), hang-gliding, martial arts, motor sports, mountaineering (including rock climbing or abseiling), ocean sailing, parachuting, para-skiing, power boat racing, professional sports, rodeo, rock fishing or any other hazardous pursuits? Yes No Yes No (c) Is the Insured Person currently using any medication (other than for colds or influenza)? Yes No Yes No (d) Has any insurance company refused, applied loadings or exclusions to a proposal for the Insured Person s superannuation, sickness, accident, trauma, lump sum disablement or disability insurance? Yes No Yes No (e) Has the Insured Person ever made a claim or is the Insured Person receiving benefits for any type of trauma, sickness, accident, war service, unemployment, workers compensation, common law or third party benefit? Yes No Yes No (f) Is the Insured Person contemplating seeking any medical advice, investigation or treatment including surgery in the near future? Yes No Yes No (g) Is there any reason why the Insured Person would say that they are not in good health now? Yes No Yes No (h) Has the Insured Person had surgical advice or treatment or been hospitalised or suffered from any accident or illness resulting in seven or more days disablement within the last five years? Yes No Yes No If the answer to any of the above questions is Yes, please give full details below. If insufficient room, continue in the space at the end of this Proposal. Date Full Details Options Guaranteed Renewable Yes No If yes, please select the guarantee period 1 year 2 years (If You select this option We will guarantee to renew Your Personal Accident cover in accordance with the cover provided in this Section and up to the Sums Insured You selected at the commencement of the Guarantee Period). Office Use Only Company premium Page 10

11 6 Land Transit Farm Goods Sum Insured Livestock Sum Insured Total An Excess of 100 applies to this Section. Office Use Only Company premium 7 Pleasurecraft Hull: Year built Make Registration No. Construction Type and length What is the maximum designed speed of the craft knots Current market value Sum Insured Motor(s): Year of manufacture Make Inboard or outboard HP What type of fuel is used? Petrol Diesel Serial no. Current market value Sum Insured 3. Sails, Mast and Spars: Year of manufacture Make Type of material Current market value Sum Insured 4. Equipment and Accessories: Comprising of anchors, oars, paddles, boat and motor covers, detachable canopies, seat cushions, lifebuoys, life jackets, fire extinguishers, extra fuel containers, lights, storage batteries, horns, bilge pumps, cooking stoves, chairs, extra propellers and equipment for towing water skiers, remote motor controls, steering equipment, ship-to-shore radio equipment, depth sounders. Current market value Sum Insured 5. Trailer: Year built Make Type Registration no. Current market value Sum Insured Total Sum Insured ( ) 6. Do you require additional Third Party liability cover? Yes No Power Craft (2 million already included) 5 million 10 million Sail Craft (2 million already included) 5 million 10 million Water Skiers 1 million 2 million 5 million 10 million Office Use Only Company premium 8 Machinery Breakdown Sums Insured must be full replacement value. Milking Plant (a) Up to 2250 litres Number of units Sum Insured (b) 2251 to 4450 litres Number of units Sum Insured (c) 4451 to 6880 litres Number of units Sum Insured (d) 6881 to 9100 litres Number of units Sum Insured (e) Over 9100 litres Number of units Sum Insured Page 11

12 Machinery Breakdown (continued) Aboveground Electric Motors (a) kilowatts (10 Hp) Number of units Sum Insured (b) 7.5 kilowatts (10 Hp) to 15 kilowatts (20 Hp) Number of units Sum Insured 3. Aboveground Pumps (a) Up to 3.75 kilowatts (4.75 Hp) Number of units Sum Insured (b) 3.75 kilowatts (4.75 Hp) to 7.5 kilowatts (10 Hp) Number of units Sum Insured (c) 7.5 kilowatts (10 Hp) to 15 kilowatts (20 Hp) Number of units Sum Insured (d) Over 15 kilowatts (20 Hp) Number of units Sum Insured 4. Submersible Pumps* (a) Up to 3.75 kilowatts (4.75 Hp) Number of units Sum Insured (b) 3.75 kilowatts (4.75 Hp) to 7.5 kilowatts (10 Hp) Number of units Sum Insured (c) Over 7.5 kilowatts (10 Hp) Number of units Sum Insured * Where the bore or well is unlined, the cover excludes removal and reinstallation costs. 5. Lighting Plant Number of units Sum Insured 6. Shearing Stands Number of units Sum Insured Are any shearing stands diesel powered? Yes No Other please enter details Number of units Sum Insured Number of units Sum Insured 3. Number of units Sum Insured 4. Number of units Sum Insured A minimum Excess of 100, plus a distance Excess (please refer to policy document), applies to this Section. Office Use Only Company premium 9 Electronic Equipment Please enter total replacement value of computers and word processors Sum Insured Please enter total replacement value of office equipment Sum Insured 3. Please enter total replacement value of non-programmable computer equipment (e.g. VDU terminals, printing terminals etc.) Sum Insured 4. Annual Sum Insured of restoring data Sum Insured Office Use Only Company premium 10 Theft Loss and/or damage to Farm Property by Theft following forcible or unauthorised removal from the Situation. Sum Insured Loss of Money following Theft. Sum Insured An Excess of 100 applies to this Section Office Use Only Company premium Page 12

13 11 Miscellaneous 11 Working Dogs Note: All dogs must be insured. Name Sex Age Colour Breed Markings Sum Insured Total 12 Wet Fleeces Provides cover against additional expenses incurred if sheep or goats are unable to be shorn because of wet fleeces following rain. Amount of insurance required Number Dates normally shorn at each shearing Sum Insured Sheep Goats / / / / / / / / Total Underinsurance applies to this cover. An Excess of one working day + 10 of the loss applies. 13 Frozen Embryos/Semen Provides cover for loss of semen or damage to the containers. The most we will pay for any one straw or ampoule is 50. Sum Insured Value of embryos/semen Value of storage containers Total 14 Educational Fees Name Age Name of educational facility Annual fees An Excess period of 21 days applies. Office Use Only Company premium Insurance History Have You or anyone else to be insured under this policy (a) ever had an insurer cancel or decline to accept or renew an insurance policy of any kind? Yes No (b) ever had an insurer impose an additional Excess or increased premium? Yes No (c) ever been placed in receivership or liquidation? Yes No If the answer to any of the above questions is Yes please give full and complete details below including name and address of insurer. Have You or anyone else to be insured under this policy (a) suffered loss or damage which would have been insured by any one of the coverages You have selected in this proposal? Yes No (b) If Yes, was a claim made on an insurer? Yes No Page 13

14 Insurance History (continued) For each question answered Yes give full details below including name and address of insurer if any and cost of all claims. Date Full details 3. During the last 5 years, have You or any person who will regularly drive Your Vehicle(s): (a) had any fines or penalties imposed for a traffic offence, other than a parking fine? Yes No (b) been convicted of any driving related alcohol or drug offences or are currently awaiting a court hearing or have charges pending for such offences? Yes No (c) had a driver s licence cancelled or suspended or been disqualified from holding a driver s licence for any period? Yes No (d) been responsible for causing any motor accident? Yes No (e) had any other incidents involving vehicle damage or vehicle theft? Yes No 4. Have You, or has anyone permanently residing with You, been convicted of any crime involving drugs, dishonesty or violence against any person or property during the last 10 years, or are currently awaiting a court hearing or have charges pending for such offences? Yes No 5. Have You been declared bankrupt and not been discharged for at least one year? Yes No 6. During the last 3 years, has any insurer refused to insure any motor vehicle for You or any person who will regularly drive Your vehicle? Yes No If You have answered Yes to any of the questions 3 to 6 above, please provide details in the space below including the name of any insurer involved. You can obtain Your driving record from the licensing authority in Your State. Date Full details If there is any other information which is special or individual to You that will be relevant to Us in deciding whether to insure You please provide details below. Declaration I/We declare and agree: that the information and answers given in this proposal are true and correct; that no information likely to affect the acceptance of this insurance has been withheld; that I/We have read the Important Notices at the head of this proposal; to make the Situation available for inspection by Allianz if so requested; that upon acceptance this insurance shall be subject to the Farm Pack Policy. I/We acknowledge that I/We have read and understood the Privacy Act 1988 information detailed above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons covered by this proposal. I/We authorise Allianz to reference the database of Insurance Reference Services Ltd or other insurers to confirm the information I/We supplied. Proposer s signature: Date: Second Proposer s signature: Date: Please check that this document has been fully completed. Page 14

15 Page 15 Premium Rating Summary Home and Contents Premium FSL GSTStamp Duty Total Excess (a) Home Building (b) Home Contents (c) Unspecified Personal Effects (d) Specified Personal Effects (e) Domestic Workers Comp. Farm Property (a) Farm Buildings & Contents (b) Fencing (c) Machinery & Implements (d) Livestock (e) Drought Relief (f) Removal of Debris (g) Additional Costs (h) Wool (i) Grain/Hay/Fertiliser (j) Accidental Damage 3. Liability 4. Motor Vehicles (a) Domestic (b) Commercial 5. Personal Accident 6. Land Transit 7. Pleasure Craft 8. Machinery Breakdown 9. Electronic Equipment 10. Theft (a) Property (b) Money 1 Miscellaneous (a) Working Dogs (b) Wet Fleece (c) Semen (d) Educational Fees TOTALS

16 Additional Information Section No. Question No. Additional Information Page 16