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      Motor Vehicle Insurance Form

      Please contact our office if you wish to insure 2 or more vehicles

      General information                                                                   *Required

      Date format: 01/01/0000

      Vehicle

      $

      Previous Insurance 

      Have you or any intended drivers, within the last 5 years, whether a claim was made or not;

      Ability

      Has any insurance company at any time, in respect of you or any other person to be covered under this policy or any person who may benefit from this insurance:

      Have you or any intended drivers:

      Important Information

      Your Duty of Disclosure

      You must tell us everything you know (or could be reasonably expected to know) that a prudent insurer would want to take into account in deciding:

      a) whether to accept your proposal and
      b) if so, on what terms.

      Examples of what you must tell us include:

      a) anything that increases the risk of a claim
      b) any criminal offending or convictions
      c) any previous insurance claims
      d) any refusal by another insurer to insure you on standard terms, or continue to insure you on standard terms.

      You must also tell us this every time this policy renews, or when you make any changes to it. If you fail to do this, we may avoid the policy retrospectively. You will have no insurance at all. When in doubt, disclose. We treat all information confidentially.

      Change of circumstances:
      You must tell us of any material changes in your circumstances after the policy starts and during the policy period.

      DECLARATION

      This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We

      a) declare that:

      i. the answers and information given by me/us in this Application are true and correct in all respects;

      ii. no information has been withheld that would affect an insurer's decision to accept this Application;

      iii. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;

      iv. I/we have read and understood the  Financial Services Guide and Privacy Statement;

      v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

      b) authorise National Insurance Group Pty Ltd to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
      Max file size: 20MB
    Submit

    National Insurance Group
    ABN:  94 219 052 354

    Authorised Representative: 1265061
    of McLardy McShane Partners Pty Ltd 
    AFSL No: 232987
    ​ABN: 14 064 465 309
    National Insurance Group endorses the Insurance Brokers Code of Practice. To obtain a copy of the code, click here.


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    Disclaimer :The information provided by National Insurance Group on this website is for general information purposes only, and it is not a substitute for professional advice.  You should always consider the PDS/Policy wording before making a decision.  Coverage may differ based on specific clauses in individual policies.  Refer to the FSG on our website or by requesting a copy for our services and remuneration details.
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