Insurance Application Form
NannySure is a product of Finsura Insurance Broking (Australia) Pty Limited
ABN 58 003 334 763 AFS Licence No. 243264 of 8 McMullen Avenue Castle Hill NSW 2154
Po Box 686 Castle Hill NSW 1765
Email: email@example.com Ph: 02 9899 2999 Fax: 02 9680 3023 Website: www.nannysure.com.au
1. Have you in the last 5 years
a. Made any claim(s) on an insurer for loss or damage? Yes No
b. Had any insurance declined or cancelled, proposal/application rejected, renewal
refused, claim rejected, special conditions or special excess imposed by an Insurer? Yes No
c. Suffered any loss or damage which would have been covered by the proposed insurance policy? Yes No
2. Have you or your partner(s) or director(s) of the business:
a. Ever been declared Bankrupt? Yes No
b. Ever been involved in a company or business which became insolvent or
subject to any form of insolvency administration eg- Liquidation or Receivership? Yes No
c. Been convicted of any criminal offence within the past 5 years (other than minor
traffic convictions)? Yes No
d. Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? Yes No
If you have answered “Yes” to any of the above questions, please give details below.
DUTY OF DISCLOSURE
The law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant
to the Insurers decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with
Insurers, that is, before we accept your proposal and also, prior to each instance you alter or renew the Policy. Each person named as
the Insured has the same duty.
Penalty for Non Disclosure: If you do not tell us everything necessary, Insurers may reduce or refuse to pay a claim; or cancel your
Policy. If you act dishonestly, Insurers may invalidate the Policy from its beginning and not be bound by the policy.
You don’t need to tell us anything which: reduces the risk; is common knowledge; we already know, or ought to know in the ordinary
course of our business; or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it
the Australian Privacy Principals. By providing us such information you consent to these practices unless you tell us otherwise. Our
DECLARATION, AUTHORITY & SIGNATURE
All answers and statements made in this application are true and accurate in every respect and no information which is likely to affect
our decision about accepting this insurance has been withheld.
Agents Authority: an agent is a person you authorise to act on your behalf. Eg – Coordinating Unit/Agency
I authorise (agents name) to act as my agent in relation to my business insurances.
Applicants Signature Name Date / /
Referred By - Coordination Unit / Agency Please provide the name
Industry Association Please provide the Name/Membership Number
PAYMENT OPTIONS - Direct Debit via Bank Account (Please select Annual Payment or Monthly instalments)
The premium will be debited 21 days after the policy Inception date unless an alternate date is required, if so please advise a date.
Annual Payment 12 Monthly Instalments Date to be Debited / /
Kindly complete the attached Direct Debit Request Form together with the proposal form & return it to our office or to your Agent.
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