Individual Carer
Insurance Application Form
THE APPLICANT(S)
Insured’s Name(s) in full
Tax Status Registered Business Yes No ABN Taxable %
Contact Numbers Home Mobile Fax
Postal Address
Suburb State Postcode
Email Address
Date of Birth / / Average Weekly Income $
Policy Inception Date / / for 12 Months
Please note the policy will start from either the date above or the date the proposal form is received by our office, whichever is the later. It will be
renewed automatically upon expiry unless written notification is sent to our office to advise that the policy is not required.
BUSINESS DESCRIPTION (Please describe your occupation)
LIABILITY SUM INSURED (Please Select One) Excess $250 Property Damage
$10,000,000 Public & Products Liability $100,000 Goods in your Physical & Legal Control
$20,000,000 Public & Products Liability $100,000 Goods in your Physical & Legal Control
PROFESSIONAL INDEMNITY SUM INSURED (Please Select One) Excess $500
Cover Not Required $500,000 $1,000,000 $5,000,000
STATUTORY LIABILITY SUM INSURED (Please Select One) Excess $Nil / $250
Cover Not Required $250,000 $500,000
GENERAL PROPERTY (Mobile Phones/Laptops) (Please Select One) Excess $250
Cover Not Required Quote Only Required (Complete below) Cover Required (Complete below)
List the items & their replacement value below
ADDITIONAL COVERS
Please note we may require additional information in order to arrange the following covers. If you select any of the following we will
be in contact shortly to discuss your requirements. See our website for more details.
Personal Accident & Illness Home & Contents Motor Vehicle& CTP Private Travel
Individual Carer
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: nannysure@finsura.com.au Ph: 02 9899 2999 Fax: 02 9680 3023 Website: www.nannysure.com.au
GENERAL INFORMATION
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
anyway.
PRIVACY NOTICE
We value your privacy. Our Privacy Policy sets out how we collect disclose and handle personal information under the Privacy Act and
the Australian Privacy Principals. By providing us such information you consent to these practices unless you tell us otherwise. Our
Privacy policy is available at www.finsura.com.au or by contacting us on 02 9899 2999.
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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signature
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QM470-0307
Direct Debit Request
To: The Manager, POLICY NUMBER
QBE Insurance (Australia) Limited (if available)
................................................................................................................
................................................................................................................
................................................................................................................
Please complete either section (1) or (2)
QBE INSURANCE (AUSTRALIA) LIMITED
ABN 78 003 191 035
Authorisation
I/We (Name in full)
Surname Given Name(s)
Business Name (as applicable)
Address
State Postcode
authorise QBE Insurance (Australia) Limited (User No. 185156) to arrange for funds to be debited under the Direct Debit system from my/our
account at the nancial institution named below.
This authorisation is to remain in force in accordance with the terms described in the Direct Debit Service Agreement, which has been read
and understood.
Signature 1)
X Date / /
2) X Date / /
(1) Financial Institution Account Details
Name of Financial Institution
Branch Name
Branch Address
State Postcode
Account Name
B.S.B. No.
/ Account No.
(Please note that not all accounts can be debited, e.g. passbook accounts. If in doubt please refer to your Financial Institution.)
(2) Credit Card Details
Card Type
Mastercard Visa Card
Cardholder’s Name
Card Number
Expiry Date /
Signature
X Date / /
.
.
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signature
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signature
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signature
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QBE Insurance (Australia) Limited ABN 78 003 191 035, AFS Licence No. 239545
Privacy
QBE includes information about how we manage your personal information in our Product Disclosure Statements and Policy booklets. You can
obtain a copy of the
QBE Privacy Policy Statement from our website www.qbe.com or contact the Compliance Manager on 02 9375 4656
or email
compliance.manager@qbe.com for further information.
QBE Insurance (Australia) Limited – Direct Debit Service Agreement
This agreement sets out the terms of the direct debit arrangements between you and us.
In this agreement these words have the following meanings:
‘You’ or ‘Your’ means the account holder whose details appear in the Direct Debit Request.
‘Us’, ‘Our’ or ‘We’ means QBE Insurance (Australia) Limited.
Our Commitment to You
We will initiate Direct Debit Payments in the manner referred to in the Direct Debit Request (DDR).
We will not charge any fees for Direct Debit transactions. You should contact your Financial Institution to check if any charges apply.
We will give you at least 14 days written notice if we propose to vary details of this arrangement including frequency of payments or
commencement date.
You may defer, alter or suspend this arrangement at any time by giving us at least 7 days written notice, prior to the due date of the payment.
You may also stop any payment or cancel the DDR at any time by giving us at least 7 days written notice, prior to the due date of the payment.
Your Commitment to Us
It is your responsibility to have sufcient cleared funds available in the account to be debited, to enable debit payments to be made in
accordance with the DDR.
Where a direct debit is returned unpaid, you will have to arrange for immediate payment either by Electronic Funds Transfer or otherwise and we
may pass onto you any resulting charges we incur.
You must ensure that the account details in the DDR are correct by checking them against a recent statement from the Financial Institution at
which the account is held.
General Information
Some Financial Institution accounts are not able to be debited. If in doubt, you should check with your Financial Institution before the DDR is
completed.
Debit payments will be made when due. We will not issue individual conrmation of payments made.
Where the due date falls on a non-business day, we will draw the amount on the next available business day.
Any queries, including disputed debit payments must be directed to us in the rst instance by calling QBE on (02) 9375 4656. Alternatively, you
can write to us at QBE Insurance (Australia) Limited, Compliance Manager, GPO Box 82, Sydney, NSW 2001.
Except to the extent that disclosure is necessary to process debit payments, investigate or resolve disputed transactions or is required by law,
we will keep your details and payments condential.
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