Fillable Declaration Form - Insurance (City of Oakland)

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Declaration Form - Insurance (City of Oakland)

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1
August 2021
Declaration Form - Insurance
Financial Advice Provider
Address
Financial Adviser
Insurer means an insurance product provider (including their associated parties)
Please complete and review this Declaration Form carefully. By signing this Declaration Form you are acknowledging that
you understand and agree to each of the statements set out in Sections A - F below.
Section A: Authority to act
I/We give the Financial Advice Provider express authority to act on my/our behalf with all Insurers in respect of obtaining and servicing
insurance products.
Section B: Fees & Commission Arrangements
I/We confirm that I/we have been provided with and have read and understood the Financial Adviser’s Disclosure Guide. I/We
understand that the Financial Adviser’s Disclosure Guide details, amongst other things, the commission, fees and expenses that may be
received by, or payable to, the Financial Adviser / Financial Advice Provider. I/We also understand and agree the circumstances in
which I/we may need to pay fees to the Financial Adviser / Financial Advice Provider (if applicable).
Section C: Relationship of Financial Advice Provider
I/We understand that:
● the Financial Adviser is a director, employee and/or contractor of the Financial Advice Provider and acts on behalf of the Financial
Advice Provider.
● the Financial Adviser and the Financial Advice Provider are members of The Loan Market Group Limited (Loan Market Group).
Loan Market Group provides services which can include a client management system, facilitating payment of commission, training,
and access to the Insurers.
● the Financial Adviser and the Financial Advice Provider are not employees, agents, partners or joint venture partners of the
Insurer(s) or Loan Market Group.
● the Financial Adviser and the Financial Advice Provider do not act on behalf of the Insurer(s) or Loan Market Group.
Section D: Privacy
D.1 Privacy Authorisation
I/We authorise my/our personal information (client information) to be collected, used and disclosed in accordance with Loan
Market Group’s privacy policy (available on Loan Market Group’s website: loanmarket.co.nz); and
I/We authorise my/our client information to be shared with the Insurer(s) and collected and used by them in accordance with
their privacy policies available on the Insurer(s)’ website(s).
D.2 Privacy Summary
The key terms of The Loan Market Group Limited privacy policy are summarised below:
Collection: The Financial Advice Provider may collect client information from a number of third parties. These
can include accountants, insurers and employers with your authorisation.
Purpose
The Financial Advice Provider will collect and hold client information for the purpose of
recommending insurance products to me/us.
Disclosure: The Financial Advice Provider may disclose client information to third parties if the Financial Advice
Provider considers it necessary to do so for the purpose above. These third parties include the
following:
● the Insurer(s)
● Loan Market Group
● service providers, e.g. organisations that provide the Financial Advice Provider with
administrative and management assistance and services
● the Financial Markets Authority and other regulators
● organisations involved in auditing the Financial Advice Provider.
Insurance Market - Winstone Partners Limited
393b Remuera Road, Remuera, Auckland 1050, New Zealand
Rory McSweeney FRPS Number 740111
2
August 2021
Prior to disclosing client information, we will take all reasonable steps to ensure the third party has
the same level of commitment to protecting the client information.
Further Use &
Disclosure:
The third parties referred to above may also use and disclose client information in accordance with
their own privacy policy. For example, in the case of an Insurer, this includes using and sharing the
information for the purpose of assessing the application and administering the policy – e.g.
information might be shared with medical professionals or accountants in the event of a claim,
authorities to assist in fighting fraud; money laundering or other criminal offences. If the Financial
Advice Provider has an ongoing commission arrangement in place with the Insurer over the term of
the policy, the Insurer will periodically disclose the premium to the Financial Advice Provider and to
Loan Market Group.
Marketing: The Financial Advice Provider and/or Insurer(s) might use client information for market research
purposes and for direct marketing purposes (whether through mail, email or telephone (including
SMS/MMS) or other electronic means) to notify me/us of products or services that may be of
interest to me/us. You have the right to opt-out of electronic direct marketing.
Consequences: I/We are not required by law to provide any personal information to the Financial Advice Provider,
but any failure to do so might prejudice my/our chances of obtaining the correct insurance cover.
Rights:
I/We have the right to request access to and correction of my/our personal information held by the
Financial Advice Provider and Insurer(s).
Obligations: If I/we provide any personal information about anyone else to the Financial Advice Provider or to an
Insurer (or authorise the Financial Advice Provider or Insurer to collect that information), I/we
confirm that such persons consent to and authorise the collection and use of their personal
information in accordance with Loan Market Group’s and Insurer’s respective privacy policies. I/We
confirm that I/we have advised such persons of their rights to access and request correction of their
personal information.
Section E: Change in Circumstances
I/We understand that:
● should my/our circumstances change after completion of an insurance application, but before the insurance cover has
been
accepted, I/we need to disclose this to the Insurer.
● omitting to do this could result in subsequent claims being declined.
Section F: Declaration
I/We have either signed below, or stated in writing or by email to the Financial Advice Provider / Financial Adviser, that I/we confirm that
I/we have read, understood and agree to the content of this Declaration Form.
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Declaration Form - Insurance (City of Oakland)

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Completed 4 April 2022

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