Commercial Motor Vehicle Insurance
Your Duty of Disclosure

You must tell us all information you know (or could reasonably be expected to know) which would influence the judgement of a prudent underwriter whether or not to accept your application, and if it is accepted, on what terms and at what cost.

Examples of information you may need to disclose include:
- any criminal convictions in the last 7 years or where imprisoned;
- if another insurer has cancelled or refused to renew insurance, or has imposed special terms;
- any insurance claim you have made in the past.
Examples of information you do not need to disclose include:
- anything we say you do not need to tell us about;
- anything that is common knowledge;
- anything you have already told us, or that we should be expected to know in the ordinary course of our business.
These examples are a guide only. If you are not sure whether you need to disclose a particular piece of information, please ask.

WHEN IN DOUBT – DISCLOSE. ALL INFORMATION WILL BE TREATED CONFIDENTIALLY.
Details of Applicant(s)
Name*

First NameLast Name
Address*

Street Address

Town / CityRegion

Postal Code
Phone *
Email*
Payment Options
How do you wish to pay?*

AnnuallyMonthly
Full Name and Address of Finance Company (or other interested parties)
Cover start date*

MonthDayYear
Date
Cover
Type of Cover: (tick cover required)*

ComprehensiveThird Party Only
Vehicle Details
Make and Model of vehicle*
Year of Manufacture*
Registration Number*
Market value of vehicle*
Does your car have any aftermarket accessories or modifications?*

YesNo
If ‘Yes’, give full details
Have all aftermarket accessories or modifications that require certification been certified?*

YesNo
Does the vehicle have a car alarm or immobiliser*

AlarmImmobiliser
Where is the vehicle usually parked at night?*

GarageDriveway/CarportRoadsideOther (Specify)
Will the vehicle be used in connection with any profession, business or occupation?*

YesNo
If ‘Yes’, give full details
Details of the Owner(s) & Driver(s)
Date of birth*

MonthDayYear
Date
Sex
Driver type*
Length licence held
Years
Licence type*
Declaration Questions
Have you or anyone else who will drive this vehicle had any motor vehicle accidents, damage or theft in the last 5 years (whether a claim was made or not)?*

YesNo
If ‘Yes’, give full details: (Date and brief description)
Have you or anyone else who will drive this vehicle ever indefinitely been disqualified from driving for repeat alcohol or drug related driving offences?*

YesNo
If ‘Yes’, give full details: (Date and brief description)
Have you or anyone else who will drive this vehicle a) ever been imprisoned for any criminal or driving offence?*

YesNo
b) had any conviction or fine for either a criminal or driving offence, within the last 7 years?*

YesNo
c) have any prosecution pending for any criminal or driving offence?*

YesNo
If ‘Yes’, give full details: (Date and brief description)
Have you or anyone else who will drive this vehicle ever had insurance declined, cancelled, or been refused renewal or had any special conditions imposed?*

YesNo
If ‘Yes’, give full details: (Date and brief description)
Additional Benefits
Loss of use - Optional benefit cost per annum $230 (Incl GST)*

YesNo
Roadside Assist - Commercial Policy Per Vehicle Per Annum - $68.25 (incl GST)*

YesNo
Agreement
I agree that:
1. Material Facts
(a) All information given to IUNZ (whether oral or written) is true and correct;
(b) All material facts have been disclosed. (See ‘Your Duty of Disclosure’);

2. Terms of Policy
The terms of IUNZ’s policy are accepted;

3. Use of Information
(a) My personal information collected by IUNZ may be:
(i) used by IUNZ to advise me of its other services;
(ii) disclosed to other members of the insurance industry and Insurance Claims Register Ltd., and to parties who have a financial interest in the subject matter of the policy;
(b) My personal information held by other members of the insurance industry and Insurance Claims Register Ltd., may be disclosed to IUNZ.

4. Agency
Anyone who assists me to complete this Application Form is acting as my agent only.

Please note: We gather information about you (including your claims history) to consider your application for insurance. If you refuse to provide it, we may decline your application. This information is held by us and you may access it. It may be passed onto other insurers you deal with, and mortgagees, etc. Your claims history is passed onto, and held by Insurance Claims Register Ltd. This enables other insurers you deal with to access it, and prevent fraudulent claims.
Name

First NameLast Name
Should be Empty:

Application – Commercial Vehicle Insurance

Commercial Motor Vehicle Insurance

Your Duty of Disclosure

Details of Applicant(s)

Payment Options

Cover

Vehicle Details

Details of the Owner(s) & Driver(s)

Declaration Questions

Additional Benefits

Agreement

IUNZ