Insurance Declaration

First Please Enter Car Owner First Name.
Last Please Enter Car Owner Last Name.
Street Address Please Enter Street Address
State Please Select State
Post Code Please Enter PostCode.
Please Enter Phone
Please Enter Email
Please Enter Employer Name
Please select Insurance Driver.
Please select an option.
Please select an option.
Please select an option.
Please select an option.
Please Enter Car Vin
Please Enter Financier
Please select an option.
In the last 5 years
Please select an option.
In the last 5 years
Please select an option.
In the last 5 years
Please select an option.
In the last 5 years
Please select an option.
In the last 5 years
Please select an option.
In the last 3 years
Please select an option.
In the last 3 years
Please select an option.
In the last 3 years
Please select an option.
Please select an option.
You must agree to the Terms & Conditions.

I also declare that I have received a copy of the Policy document, read the information concerning the duty to take reasonable care not to misrepresent and other important notices, answered every question fully and frankly, either completed this form personally, or if it has been completed by someone else, I have checked that the questions have been fully and accurately answered.

Please be advised that the initial approval of this application is based on the information provided and that if additional information is required, you may be contacted by the insurer.

PLEASE NOTE: This application and any quote given is subject to full assessment by the Insurer. Any failure to provide the correct information may give the Insurer the right to deny any claim.

Your Duty to take Reasonable Care not to Misrepresent
You have a duty to take reasonable care not to make any misrepresentation when entering into, varying, extending or renewing the Policy.
This means that it is essential that You respond to specific questions that We ask honestly and to the best of your knowledge, including where We ask You to confirm or update information that You have previously given to US when entering into, varying, extending or renewing the Policy.
To assist You with providing Us with honest and accurate responses to any questions We ask of You, We have endeavoured to ensure that any question We ask are clear and easy to understand. Further, where possible, We have also included examples of the types of responses We are looking for when asking a particular question.
If You are unclear of any particular question or would like us to explain it to you, please get in touch with us and we will explain this to you.

In determining whether You have fulfilled this duty to take reasonable care not to make a misrepresentation to Us, We will consider all of the relevant circumstances of a particular case. If You do not respond honestly and accurately to specific questions that We ask, We may (acting reasonably) cancel Your contract or reduce the amount We will pay You if You make a claim, or both. It is therefore vital that you be honest and specific in Your responses. If Your failure to tell Us is fraudulent, We will refuse to pay a claim and treat the Policy as if it never existed (this does not mean that We will refund any premiums that You have already paid).

ADDITIONAL INFORMATION
Should there not be enough room to provide your answers to the questions herein, please provide your response in a separate document attaching and forming part of this application for insurance.

PRIVACY ACT 1988
Pay@bility is committed to protecting your privacy and the confidentially and security of personal information provided by you to us. We are therefore bound by the National Privacy Principles and the Privacy Act 1988 (Cth).

Information We Collect
All the information that we ask for is required for us to effectively coordinate your vehicle insurance and to provide you with the benefits available to you as part of the Pay@bility Fleet Management package.

Right of Access
You have the right to access any such information held by Pay@bility that relates to you and to collect any information that is inaccurate. If you object to us using the information as described you can advise us at any time by writing to: pay@bility.com.au.

Permission
I give express permission to receive Product Disclosure Statements and/or other relevant documentation electronically.