Limousine Insurance Proposal Form, Zurich

Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. Taxi/Chauffeur/Hire Vehicles Proposal – of 4

Taxi/Chauffeur Driven and Hire VehiclesProposal form

Duty of DisclosureBefore you enter into this contract of insurance with us, the Insurance Contract Act 1984 requires you to tell us everything which you know, or could be reasonably expected to know, is relevant to our decision whether to accept the risk of the insurance and, if so, on what terms. The duty of disclosure is different depending on whether it is a new policy or not.

New Business

Where you are entering into this policy for the first time (that is, it is new business and is not being renewed, varied, extended or reinstated) you must tell us everything you know, or could be reasonably expected to know, in answer to the specific questions we ask.

When answering our questions you must be honest.

Who needs to tell us

It is important that you understand that you are answering our questions in this way for yourself and anyone else whom you want to be covered by the policy.

If you do not tell us

If you do not answer our questions in this way, we may reduce or refuse to pay a claim, or cancel the policy. If you answer our questions fraudulently, we may refuse to pay a claim and treat the policy as never being in force.

Renewals, variations, extensions and reinstatements

Once your policy is entered into and is no longer new business then your duty of disclosure to us changes. You are required before you renew, vary, extend or reinstate your policy, to tell us everything you know, or could be reasonably expected to know, which is relevant to our decision whether to renew, vary, extend or reinstate the contract of insurance and, if so, on what terms.

You do not have to tell us about any matter:

– that diminishes the risk;

– that is of common knowledge;

– that we know or should know in the ordinary course of our business as an insurer; or

– which we indicate we do not want to know.

If you do not tell us

If you do not comply with your duty of disclosure we may reduce or refuse to pay a claim or cancel your policy. If your non–disclosure is

fraudulent we may refuse to pay a claim and treat this policy as never being in force.

PrivacyThe National Privacy Principles, under the Privacy Act 1998, regulate the way in which private sector organisations like Zurich can collect, use, store and disclose your personal information.

We collect personal information about you in order to assess your request for insurance and to administer the policy. You can elect not to provide us with your personal information however we may then not be able to process your application for insurance, we may not be able to process your claim or you may breach your Duty of Disclosure.

In some circumstances, we may collect and/or disclose your personal information (other than sensitive information such as health information) to a third party such as your intermediary, our service providers and our business partners. A list of service providers and business partners that we may disclose your personal information to and for further information on our Privacy Policy, please refer to the Privacy link on our homepage – www.zurich.com.au.

By providing us with your personal information, you consent to us disclosing your personal information for these purposes.

In most cases, at your request, we will give you access to the personal information we hold about you. In some circumstances we may charge a fee for giving you access, which will vary but will be based on our costs.

If you would like to find out more, you can contact us by telephone on 132 687 or email at [email protected] or in writing to:

The Privacy OfficerZurich Australian Insurance LimitedPO Box 677North Sydney NSW 2059

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Important information – Please read the following before completing this proposal.

Policy detailsFor full details of cover, please refer to the Product Disclosure Statement which sets out the terms and conditions of cover offered. This is available from your intermediary or your local Zurich branch office.

Taxi/Chauffeur/Hire Vehicles Proposal – of 4

Vehicle details

Date this vehicle first became registered as a taxi? Month Year

Please 4 tick to indicate type of vehicle

Sedan/Wagon cab (Non-prestige vehicle) Prestige/Silver service can

Maxivan (Wheelchair accessible) cab Flashcab (wheelchair accessible)

Chauffeur driven/Hire vehicles (HC Plated) StandBy

Other If 'Other', advise type of vehicles

Does the vehicle operate under a restricted plate? Yes No If 'Yes', please provide details

Make Model Year

Registration Number Engine Number

Engine size / type Transmission

If vehicle is a taxi, detail name and location radio base to which Taxi is attached

If vehicle is a chauffeur driven/hire vehicle, advise the postcode where vehicle is garaged

Proposed period of insurance

Period of insurance: From / / To / / at 4pm, local time

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All questions in this proposal form must be answered

Insured details

Agent / Broker

Operators/Lessee name

Operators/Lessee address Postcode

Operators/Lessee accreditation number

Is the vehicle subject to finance? Yes No If 'Yes', provide name and address of financier

Name

Address Postcode

Type of finance Lessor Owner Secured Loan Hire Purchase Other

Do you own/operate 5 or more taxis? Yes No

Have you ever traded under any other business or entity name? Yes No If 'Yes', please provide details

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Motor insurance optionSelect either Composite Cover OR Third Party Property Damage Only Cover (TPPDO).

Composite Cover means – Loss or damage to your vehicle plus your Liability whilst using the vehicle for damage to property belonging to persons other than you.

Third Party Property Damage only means – The Cover is restricted only to your Liability whilst using the vehicle for damage to property belonging to persons other than you.

COVER REQUIRED – Select Composite Cover or Third Party Property Damage only

Please 4 tick alongside the Cover required Composite Cover OR TPPD, Total loss & perils OR TPPD only cover

Please 4 tick alongside the Limit of Liability required for Third Party Property Damage

$5,000,000 OR $10,000,000 OR $15,000,000 OR $20,000,000 Or please specify amount required

$

Please advise what Excess is required

$1,000 OR $1,500 OR $2,000 OR $3,000 Other $

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Motor insurance option (continued)

If you selected COMPOSITE COVER, please answer the following questions

Vehicle value $

If your vehicle is a taxi, do you require the Encumbered Vehicle Extension? Yes No NA

If 'Yes, please detail the percentage amount of cover required in excess of the Taxi Value 10% 20%

Do you require loss of use? Yes No

NOTE: The Taxi Value must represent the present value of a standard factory vehicle, including the value of any LP gas fittings, meter and external vacancy roof light (if fitted) but not including:

• non-factorystandardaccessories–whichmustbeitemisedundertheaccessoriessectionbelowifcoverisrequiredforthem;or

• anysafetyscreen,surveillancecamera,Eftposequipmentorglobalpositioningsystemincorporatingmobiledateterminaland2/wayradio(if fitted) – which must be identified below if cover is required for them.

Please list all accessories fitting to your vehicle that you want to cover that are not factory standard eg. mag wheels, compact disk player, sunroof, bull bars etc.

Accessory item Value

$

$

$

$

$

Total $

Do you want to insure your safety screen? Yes No

Do you want to insure your surveillance camera? Yes No

Do you want to insure your Eftpos equipment? Yes No

Do you want to insure your global positioning system (incorporating data mobile & associated cabling terminal)? Yes No

Do you want to insure your radio equipment and aerial? Yes No

Do you want to insure your MT Data System? Yes No

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Claims history/No Claim BonusIn the last five (5) years, have there been any claims made against previous insurers of this vehicle, or if replacing another vehicle, any claims in respect of the replaced vehicle? Yes No

If 'Yes', please attach claims history on previous insurer's letterhead to this proposal form.

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General Liability insurance optionGeneral Liability means your liability for personal injury or property damage that occurs in connection with the business of hiring your vehicle for reward. There are a number of exclusions applicable to this cover, such as workers compensation liability, motor vehicle compulsory third party liability and liability arising out of the use of a registered motor vehicle. Please refer to the Policy wording for the full terms and effect of the exclusions.

Do you require General Liability as a vehicle operator. Please 4 tick 'Yes' or 'No' Yes No

Please 4 tick alongside the Limit of Liability required for Third Party Property Damage

$5,000,000 OR $10,000,000 OR $15,000,000 OR $20,000,000 Or please specify amount required

$

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General questions

(a) Has any vehicle under this cover been issued a default notice? Yes No

(b) Does your vehicle have any mechanical or any other problems that make it unsafe? Yes No

If 'Yes', supply details

(c) Has any insurance company cancelled, declined or refused to renew or imposed special terms or conditions on any policy held by you? Yes No


(d) In the last three (3) years, have you been involved in any accidents and/or lodged a claim in connection with any motor vehicle? Yes No


(e) In the last (5) years, have you been declared bankrupt, been convicted of a criminal offence including any convictions for driving under the influence of alcohol or drugs (DUI)? Yes No


(f) Does your vehicle have any rust, hail or other unrepaired damage? Yes No

If Yes, supply details

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DeclarationI / We agree that you may release information on any claims made by me / us in the last 5 years and/or under this Policy (including without limitation, the name, age, licence number and driver authority number of the person driving the vehicle giving rise to any incident which gives rise to a claim under the Policy) to the Limousine Association and any other entity which is or may become involved in insuring chauffeur driven limousine vehicles / hire vehicles. I/we understand that the release of such information is necessary to enable you to properly assess risk under the Policy. I / We agree to draw this provision to the attention of every person driving the vehicle.

In accordance with my / our duty of disclosure, I / We declare that the whole of these answers in the Proposal are true and that I / We have withheld no information whatever that might tend in any way to increase your risk, or to influence your decision regarding this Proposal.

I / We agree that this Proposal and Declaration shall be the basis of the contract between me / us and you and I / We understand that this is not Compulsory Third Party (CTP) insurance.

I / We further agree that if this Proposal, in any part, is completed or signed by any other person, such person shall be deemed my / our agent(s) and not the agent of you.

Letter of Authority

I / We agree this engagement permits Zurich Australian Insurance Limited to obtain any information deemed necessary from any insurer or insurance intermediary relative to my insurance. This includes claims details and claims experience required for the review of our present and future insurance requirements.

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Signature Date

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Limousine Insurance Proposal Form, Zurich

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