Pleasure Craft Proposal

Transcription

1 Marine Pleasure Craft Proposal

2 Pleasure Craft Proposal Personal Details Owner s Full Name: Postal Address: (Please complete in block letters) Date of Birth: Telephone No. (daytime): (Optional): Names of Joint owners or mortgagees if any: Mobile No.: Mortgage amount: Vessel Details Name of Vessel: Make: Model: Hull Construction: Wood Steel GRP Carbon Fibre Other If Other please specify: Mast Construction: Wood Aluminium GRP Carbon Fibre Other If Other please specify: Is Vessel Production Model or One Off Design Dimensions: Length (excluding spars & pulpits): Date of Last Survey: Extreme Breadth: Date Purchased: Draft in working trim: Price Paid: Year Built: Number of crew on board/required to crew the Vessel: Engine Details Twin or Single Screw: Maker: Year Built: Maximum Designed Speed: What fuel is used in: Main engines? HP of each engine: Serial Number: Auxiliary machinery? Fire Precautions What fire extinguishers are kept on board? Is any petrol used or stored below deck? Yes No Is the vessel fitted with bottled gas equipment? Yes No If so, is all delivery tubing made of copper? Yes No If No, please give details: Experience Years Sailing: Length & Make of Previous Boats Owned: ISA & ISA Affiliated Sailing Courses Taken and Qualifications Obtained:

3 Insurance Record Have you had any accidents or losses during the last 5 years? Yes No If Yes, please give details: Has any Insurer declined your proposal, refused renewal of your policy, loaded the premium or imposed special conditions? Yes No USE Will the Vessel be used for purposes other than private pleasure? Yes No If Yes, please give details: Will you allow others to use the Vessel in your absence? Yes No If Yes, please give details of sailing experience and qualifications of additional users: Will the Vessel be used for waterskiing or wakeboarding? Yes No Will the Vessel be used for the towing of rings? Yes No Will the Vessel be used for the towing of bananas or similar? Yes No Will the Vessel be used for or in connection with parascending or similar? Yes No Do you require cover for racing risks? (ie damage to masts, spars, sails, standing and running rigging while racing) Yes No If Yes, please state: age of masts, spars, sails, standing and running rigging: the full replacement cost of masts, spars, sails, standing and running rigging: Will spinnaker be used? Yes No Please state cruising range required: Mooring Details Where is the Vessel normally moored when in commission? Which months of the year will the Vessel be laid up: From: Where will the Vessel be laid up: Ashore Mud Berth Marina Other If other please specify: To: Cover Required Sums to be insured: Please complete each of the following where applicable Hull, machinery, equipment etc.: Dinghy and/or tender*: Please state the limit of indemnity required for any one accident required in respect of claims by Third Parties and Outboard Motor: Passengers: Auxiliary Motor: 1,500,000 Other Trailer / Trolley List and value all items over 300 for each of the following Electronic Equipment: Special Equipment: Personal Effects: Other Equipment: Total Sum Insured: * Dinghies and tenders must be permanently marked with the name of the insured vessel. I wish to pay by: Cash/Cheque MasterCard/Visa Laser Card Direct Debit

4 Proposer Proposers name: Policy Number: (for office use only) If your address has recently changed: please fill in the new one below: Card Payment To pay by Laser, Visa or Mastercard, simply complete the authorisation form below. I authorise you to Debit my Account with the amount of Name (as on your card): Policy Number: Date Card Expires: Tel. Contact No.: Please tick Cardholder s Address: My Account No. is: Cardholder s Signature: Date: Direct Debit DIRECT DEBITS: This Direct Debit facility allows policyholders to pay for their Insurance monthly in advance over a 12 month period. To use this facility, simply complete the Direct Debit Instruction and return this entire form, before the premium due date together with a cheque for the first monthly premium. The remaining monthly premiums will be automatically deducted by direct debit over 11 consecutive months. MID-TERM ALTERATIONS: If any mid-term alteration to the policy results in an increase in the monthly premium we will not apply any service charge (where applicable) to the increase. REFUNDS: If the policyholder receives a refund of any premium, we will also refund the service charge (where applicable). DEFAULTS: If the accountholder fails to make a monthly payment, we may cease this Direct Debit facility. In that event, and if the policyholder wants to continue cover under this policy, the balance of the annual premium will be payable in full and if not received we may cancel this policy. CANCELLATIONS: This Direct Debit may be cancelled at any time without penalty. To then maintain cover, all the policyholder has to do is pay the balance of the annual premium no later than the next monthly payment date. CONTINUING DIRECT DEBIT AUTHORISATIONS: By delivering the Direct Debit Instruction to Allianz p.l.c. for the purposes of the Policy of insurance referenced therein, you hereby authorise Allianz p.l.c. to submit the Direct Debit Instruction to the Accountholder s Bank/Building Society, and to continue to request payments against the Direct Debit Instruction in respect of this Policy of insurance, for each period of insurance for which Allianz p.l.c. may issue renewal terms. Allianz p.l.c. shall stand so authorised for all payment dates up to and including the date that this Direct Debit instruction is cancelled. Policy Number: Annual Premium: ** Service Charge: Total Due: To be paid in 12 monthly premiums of Service Charge Rate 8.00% **Charge is a service charge and not an interest charge. Equivalent to an Annual Percentage Rate of 18.63% Instruction to your Bank/Building Society to pay Direct Debits Originators I.D Please complete parts 1 to 4 to instruct your Bank/Building Society to make payments directly from your account. Then return the form to: Allianz p.l.c., Allianz House, Elmpark, Merrion Road, Dublin 4. FOR OFFICE USE ONLY: 1 ORIGINATORS REFERENCE (POLICY NO.): 1. PLEASE WRITE THE NAME AND FULL ADDRESS OF YOUR BANK/BUILDING SOCIETY AND BRANCH BANK/BUILDING SOCIETY: ADDRESS: 2. NAME OF ACCOUNTHOLDER: 4. YOUR INSTRUCTIONS TO THE BANK/BUILDING SOCIETY, AND YOUR SIGNATURE: I instruct you to pay direct debits from my account at the request of Allianz p.l.c.. I confirm that the amounts to be debited are variable and may be debited on various dates. I shall duly notify the Bank/Building Society in writing if I wish to cancel this Instruction. I shall also notify Allianz p.l.c. of such cancellation. THE DIRECT DEBIT GUARANTEE This is a guarantee provided by your own Bank/Building Society as a member of the Direct Debit Scheme, in which Banks/Building Societies and Allianz p.l.c. participate. If you authorise payment by Direct Debit then: Allianz p.l.c. will notify you in advance of the amounts to be debited to your account. Your Bank/Building Society will accept and pay such debits, provided that your account has sufficient available funds. If it is established that an unauthorised Direct Debit was charged to your account, you are guaranteed a prompt refund by your Bank/Building Society of the amount charged. You can cancel the Direct Debit Instruction by writing to your Bank/Building Society in good time. ACCOUNTHOLDERS SIGNATURE: (1) (2) 3. SORT CODE: BANK / BUILDING SOCIETY ACCOUNT NO.: DATE: BANKS/BUILDING SOCIETIES MAY DECLINE TO ACCEPT INSTRUCTIONS TO CHARGE DIRECT DEBITS TO CERTAIN TYPES OF ACCOUNTS OTHER THAN CURRENT ACCOUNTS

5 Material Facts Declaration Continuing Obligation As evidenced by your signature(s) below, you declare that the information given in this Proposal Form is true in every respect and that you have not withheld or misrepresented any material fact. You acknowledge the serious consequences of failure to disclose all material information as this may lead to voidance of your policy. Such information is that which the Company would regard as likely to influence its assessment and acceptance of this insurance. You accept that you have a continuing obligation to disclose to the Company such material information immediately on becoming aware at any time during the period of this insurance of any material change that may affect this insurance or increase the risk of loss, damage or injury. You agree that if there is any doubt as to whether or not any information is material, you will disclose it. You agree that this proposal form will form the basis of the contract between you and the Company. If any answer has been written by a person other than the undersigned, you agree that such person shall be your agent and not an agent of the Company. Data Protection Acts collection and use of personal information In these statements references to information include personal data and information given by you to Us, whether in your Proposal, any claim form you submit to Us or otherwise, any information We may collect in connection with any product or service We provide, information made available about you disclosed to Us by another party in connection with the transfer to Us of such party s rights and duties to you under any other insurance arrangements. Allianz p.l.c. is a member of the Allianz Group, and shall be the data controller in respect of all such information. References to We and Us in these statements and consents shall be construed accordingly. USES. Information you supply may be used for the purposes of insurance administration (including underwriting, processing, claims handling, reinsurance and fraud prevention) by Us, our agents, our reinsurers and any intermediary acting for you. In assessing any claims made, We may undertake checks against publicly available information such as electoral roll, court judgements, bankruptcy or repossessions. DISCLOSURE. We may share with our agents and service providers, members of the Allianz Group, other insurers and their agents, and with any intermediary acting for you, and with recognised trade, governing, and regulatory bodies (of which We are a member or by which We are governed), information We hold about you and your claims history. This includes Insurance Link, the Irish Insurance Federation's anti-fraud claims matching database. We may in certain circumstances use private investigators to investigate a claim. SENSITIVE DATA. We may need to collect sensitive data relating to you (such as medical or health record or condition, convictions etc.) in order to assess the terms of insurance We issue/arrange or to administer claims which arise. By your signature you signify your consent to such information being used, processed and disclosed by Us, our agents and other insurers for the purposes of insurance administration (including underwriting, processing, claims handling, reinsurance and fraud prevention). RETENTION. We will not retain your data for longer than is necessary for the purposes for which it is obtained. If you provide personal data to Us and you do not become an insured We will not retain your data for longer than 15 months from the date of collection unless you are a direct customer and have not objected to direct marketing purposes (as detailed below in the Direct Marketing paragraph). CONSENT. By providing Us with your information and by your signature you consent to all of your information being used, processed, disclosed and retained for the purposes of insurance administration (including underwriting, processing, claims handling, reinsurance and fraud prevention). REPRESENTATION. By your signature you warrant and represent to Us that in respect of any personal data of any data subject which you provide to Us, you have the authority of that data subject to disclose such data to Us on these terms and conditions and for all the purposes herein set out and to give the consents set out above on behalf of each such data subject, and accordingly, all references in these statements to 'you' or 'your' shall be deemed to include any such data subject. ACCESS. You have the right to request and receive a copy of your personal data held by us. Should you wish to exercise this right, you should write to us under Section 4 of the Data Protection Acts 1988 and 2003, for the attention of the Data Protection Officer, at Allianz House, Elm Park, Merrion Road, Dublin 4. A fee of 6.35 is chargeable and cheques should be made payable to Allianz. CALL RECORDING. Calls may be recorded or monitored for regulatory, training and quality purposes. The paragraph below applies only to direct customers. DIRECT MARKETING. The Allianz Group and its agents and business partners may use your information to keep you informed by post, telephone, , SMS or other means of products and services which may be of interest to you and We may disclose your information to any such Group member, agent or business partner for such purposes. Your information may also be disclosed and used for these purposes after your policy has lapsed. If you do not wish your information to be used for these marketing purposes please write to Us at Allianz House, Elmpark, Merrion Road, Dublin 4 or Us at info@allianz.ie. Signature(s): Proposer(s) Signature 1) Date 2) Date N.B. Before signing the Proposal Form please ensure that all the questions have been fully answered. If they have not, the form will be returned to you for completion. Cover does not commence until formally confirmed by the Company or its authorised insurance intermediary. A copy of the completed Proposal Form and a copy of the Policy Document are available on request.

6 Allianz p.l.c., Allianz House, Elmpark, Merrion Road, Dublin 4. Telephone: (01) Fax: (01) Website: Allianz p.l.c. is regulated by the Financial Regulator. Registered in Ireland, No MAR 05/09 KD