Truck Insurance HQ

Truck Insurance Specialists

Would you like a quote for Commercial Motor Insurance?:
Yes No

Title *:

First Name *:

Last Name:

Insured Name:

Contact *:

Email *:

Confirm Email *:

Address

Street Address *:

City *:

State *:

Postcode *:

How many years current continous commercial motor insurance has been held:

Current Insurer

Renewal Date

Any driver under the age of 25 or been licensed in Australia for less than 2 years for the applicable vehicle licence class.
Yes No

Any driver had a loss of licence, DUI or drug offense in the last 5 years.
Yes No

Any driver had 2 or more traffic infringement in the last 2 years.
Yes No

Any driver has had a commercial motor vehicle claim in the last 5 years.
Yes No

Description	Year	Payout
			Add New

The insured and any drivers have never been convicted of a criminal offense, bankruptcy, liquidation or receivership?
Yes No

In the past five years, has the insured or its directors made any claim for commercial motor vehicle insurance or suffered any insured or uninsured loss which would be covered by the insurance being applied for? *:
Yes No

Description	Year	Payout
			Add New

Are you aware of any incidents in the past five years which may give rise to a claim being made against You, Your business or any person to be covered by this insurance?
Yes No

Additional information (if answered ‘yes’ to any of the above)

Declaration

Have you or any director, partner, manager of the business ever:

Please select all the require field

Had any insurance declined or cancelled?:
Yes No

Had an insurer refuse or not invite renewal?:
Yes No

Had any special conditions imposed on a policy of insurance?:
Yes No

Had a special excess imposed on a policy of insurance?:
Yes No

Had a claim rejected under a policy of insurance?:
Yes No

Been charged with or convicted of a criminal offence?:
Yes No

Had an insurer refuse or not invite renewal?:
Yes No

Duty of Disclosure

Before you enter into a contract of general insurance with an insurer, You have a duty under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know that may be relevant to the decision of the insurer wheather to accept the risk of the insurance and, if so, on what terms. The same duty arises at renewal, extension, variation or reinstatement of the policy. Your duty, however, does not require disclosure of any matter:

That diminishes the risk insured under the policy;
That is of common knowledge;
That the insurer knows or, in the ordinary course of its business, ought to know; and
As to which compliance with your duty has been waived.

This duty continues until the time the policy is issued and applies to all persons to be covered under this policy. If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the policy in respect of a claim or cancel a policy. If the non-disclosure is fraudulent, the may also have the option of avoiding the policy from its beginning. By submitting this application form you hereby declare that:

You are the listed insured, or authorised by the listed insured to organise insurance on their behalf *:
Yes No

If there is more than one insured, you are authorised to organise insurance on their behalf, and that if you disclosed personal information about any insured person or any other person, you have made them or will make them aware that you have provided their personal information to us and the types of third parties we may provide it to, the relevant purposes we and third parties will use it for, and how the insured person or other person can access it *:
Yes No

The disclosed information is true and correct *:
Yes No

You have not withheld or supressed any information concerning the details of this application *:
Yes No

You have read the above duty of disclosure and are aware that should you not fully and truthfully disclose all relevant information, an insurer may decline a claim or void a policy *:
Yes No

You consent that any personal information you provide Truck Insurance HQ/NAS Insurance Brokers will be collected, stored, used and disclosed in accordance with our Privacy Policy. We may provide your information to insurance companies and other intermediaries in order to provide insurance quotes and offer insurance terms to you or the companies that deal with your insurance claim (such as loss assessors and claims staff) *:
Yes No

You are aware that no insurance is in force until such time that the insurer accepts this proposal of insurance, and that this proposal of insurance/application will form the basis of the insurance contract between the insured and the insurer. *:
Yes No

You acknowledge that any premiums stated are indicative only and subject to insurer confirmation, and may change based on the information you have provided *:
Yes No

You acknowledge that in the event cover is placed, and cover subsequently cancelled an insurance placement fee of $100 per policy will apply *:
Yes No

Would you prefer to pay your premiums monthly? *:
Yes No

Would you like to speak to a specialist who can help with your life, trauma, total & permanent disablement, income protection and superannuation needs? *:
Yes No

Do you want to speak to someone about income protection? *:
Yes No

Free Written: