Catlin Australia Pty Ltd, trading as Brooklyn, an XL Group Platform (ABN ) (AFSL ).

Transcription

1 INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Catlin Australia Pty Ltd, trading as Brooklyn, an XL Group Platform (ABN ) (AFSL ). Guidelines to help you complete this Proposal Form 1. Failure to disclose all material information that is likely to influence the acceptance of the risk or the terms applied could invalidate the insurance. If you are in any doubt as to whether any information is material, it should be disclosed. 2. Where the space provided is insufficient for your replies, please provide these separately and attach to this Proposal Form. 3. The terms proposer, whenever used in this proposal form shall mean the insured listed and all subsidiary companies of the insured for which coverage is proposed under this proposal. 4. The terms insured and subsidiaries have the same meaning in this proposal form as in the policy. Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of insurance, and if so, on what terms. You have this duty until we agree to insure you. Your duty of disclosure before you renew, extend, vary or reinstate an insurance contract is to tell us before the renewal, variation, extension, reinstatement or replacement is made, every matter known to you which: you know, or a reasonable person in the circumstances could be expected to know, is relevant to our decision whether to insure you and whether any special conditions need to apply to your policy Your duty however does not require disclosure of any matter: That diminishes the risk to be undertaken by the insurer; That is of common knowledge; That your insurer knows or, in the ordinary course of this business, ought to know; As to which compliance with your duty is waived by the insurer. If we request personal information about you and you do not provide it, we may not be able to provide you with the insurance product you request, manage or pay any claim under an insurance policy or provide you with the full range of services we offer. Privacy Brooklyn is bound by the Privacy Act 1988 and requires us to inform you that: We collect, disclose and handle personal and/or sensitive (e.g. health) information, about you ( personal details ) for the purposes of; identifying you when you do business with us; protecting your personal information from unauthorised access; establishing your requirements and providing the appropriate product or service including evaluating your application for insurance and any request for amendment to any insurance provided; setting up, issuing, administering and managing the insurance following acceptance of an application; assessing and investigating, and if covered, manage claims and improving our financial products and services, including training and developing our staff and representatives. We may disclose your details, including your sensitive information, to intermediaries including your agent, adviser, a broker, a representative acting on your behalf, other Australian Financial Services Licensee or our authorised representatives and our agents, other insurers and reinsurers, our service providers, our business partners, health practitioners, your employer, parties affected by claims, government bodies, regulators, law enforcement bodies and as required by law, within Australia and overseas. Our Privacy Policy contains information about how you can access the information we hold about you, ask us to correct it, or make a privacy related complaint. You can obtain a copy from our Privacy Officer by telephone (+61 (0) ), or by visiting our website ( By providing us with your personal information, you consent to its collection and use as outlined above and in our Privacy Policy. INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 1

2 1. DETAILS OF THE PROPOSER Full name of the Insured: Gender: Male Female Address: State: Post Code: Date of Birth: Height (cm) Weight (kg) Occupation: Nature of work: Are you self-employed? Yes No Weekly salary: $ or If No, are you covered by Workers Compensation? Yes No Annual Turnover: $ 2. INSURED PERSONS ACKNOWLEDGMENT YES NO More details (If Answered Yes) Are you a permanent resident of Australia? Do you have any hazardous pastime activities that you engage in frequently (e.g Quad biking, scuba diving) and/or participate in amateur or professional sports? Are you or have you ever been a smoker? Are you currently taking any medication (both prescription and non-prescription)? Do you have any pre-existing conditions? Have you received treatment by a registered medical practitioner (e.g. doctor, nurse, psychiatrist) for any injury or sickness in the last 5 years that required hospitalisation, long term treatment or prolonged time away from work? Are there any circumstances relating to your occupation that may make you more liable to injury or sickness (e.g heavy lifting etc.) At present, do you have any reason to consider yourself not in good health? Have you ever had irregular blood pressure, ulcers, diabetes, tuberculosis, cancer, paralysis, arthritis, tumours or rheumatism or any disorders of the mental, respiratory, nervous, genile-urinary, digestive, or circulatory, spinal systems? INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 2

3 3. CURRENT COVER Do YOU currently hold or have previously held any Personal Accident insurance? Yes No If YES, please provide full details: Name of Insurer: Capital sum Insured: Renewal Date: Weekly Sum Insured: 4. SCOPE OF COVER - Please select when you would like to be covered: *Please select one option 24 hours, 365 Days During working hours only including commute to and from work During working hours only Outside working hours only 5. BENEFITS REQUESTED - Please advise what you would like to be covered for: Part A - Lump Sum Benefits (Events 1-19) $ Part B - Weekly Injury (Events 20 and 21) $ Part C - Weekly Sickness (Event 22 and 23) $ Waiting Period (Days) Benefit Period (Weeks) Other: Other: Part E - Monthly Business expenses (Event 33, for self-employed persons only) $ ABN (if monthly expenses required): INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 3

4 6. PERIOD OF INSURANCE From (Inception): To (Expiry): 7. PREVIOUS INSURANCE HISTORY Has any insurer, in respect of the risks to which this proposal relates, ever: a) Declined a proposal, refused renewal or terminated any insurance? Yes No b) Declined an insurance claim by the Proposer or reduced its liability to pay an insurance claim in full (other than by application of an excess)? Have you ever claimed for benefits or lodged a claim under an Accident or sickness policy in the past? (If yes, please complete the below). Details of Accident and/or Sickness claim: Name of Claimant: Amount of claim ($): Insurer Name: Date of claim: Status/outcome: INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 4

5 8. DECLARATION I/We the undersigned duly authorised person(s) declare that: i. The above statement are correct, true and complete; and ii. No information material to this Proposal Form has been withheld; and iii. I/We have read the important facts which you have put before me/us and I/we understand the advice given in relation to necessary and detailed enquiries in order to comply with the duty of disclosure; and iv. I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and v. I/We acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance. Signature of Insured or Authorised Representative: Date: Print Name: INDIVIDUAL PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 5