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Dawes Motor Insurance
Dirt Bike Insurance Application
www.dawes.com.au
IMPORTANT NOTICES
The Insurer and Authorised Representative
Privacy
This policy is arranged by Dawes Underwriting Australia Pty Ltd trading as
Dawes Motor Insurance (ABN 18 050 289 506, AR No. 342982) (Dawes)
as an Authorised Representative of Calliden Insurance Limited (ABN 47 004
125 268, AFSL 234438), the insurer of the product.
Both Calliden and Dawes respect your privacy. Any personal information
provided by you will be treated in accordance with the Privacy Act 1988
(Cth). This privacy notification provides a summary of how Calliden and
Dawes treat your personal information.
General Insurance Code of Practice
Calliden and Dawes primarily collect your personal information via this form
to assess your request for insurance and to administer your policy but
may also use this information to settle an insurance claim, provide other
insurance services as requested by you, and also to notify you about other
services or promotions from time to time.
Calliden is a signatory to the General Insurance Code of Practice (Code).
The Code aims to raise standards of service between insurers and their
customers. Calliden’s service standards are in accordance with the Code.
For any information about the Code, including a copy of the Code, contact
us or the Financial Ombudsman Service on 1300 78 08 08 or visit www.codeofpractice.com.au
Your Duty of Disclosure
Whether you are entering into a policy for the first time or are proposing to
renew, vary, extend or reinstate a policy you have a duty of disclosure.
Your duty of disclosure for new policies
When answering our questions you must be honest and you have a duty
under law to tell us anything known to you, and which a reasonable person
in the circumstances, would include in the answer to the question. We will
use the answers in deciding whether to insure you and anyone else to be
insured under the policy, and on what terms.
Your duty of disclosure for renewals
If you have already entered into a policy and you are proposing to renew,
vary, extend or reinstate the policy, your duty of disclosure changes. You
have a duty to tell us of everything that you know, or could reasonably be
expected to know, that is relevant to our decision to insure you and to the
terms of that insurance. If you are not sure whether something is relevant,
you should inform us anyway.
Who needs to tell us?
It is important that you understand you are answering our questions in this
way for yourself and anyone else that you want to be covered by the policy.
What you are not required to disclose
Your duty does not require disclosure of matters that:
• reduce the risk
• are common knowledge
• we know or, in the ordinary course of our business, ought to know, and
• we have indicated we do not want to know.
If you do not tell us
If you do not answer our questions in this way or disclose everything you
know, 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
this policy as never having been in force.
If you do not provide the information requested you may breach your duty
of disclosure, your application may not be capable of being accepted,
additional conditions may be imposed on any cover provided or your policy
may not be able to be administered.
In order to provide its insurance services Calliden and Dawes may need to
disclose your personal information to third parties including, but not limited
to: agents, underwriters, advisors and brokers; claims management and
other service providers; claims adjusters, loss assessors and other claims
investigators; lawyers; reinsurers and reinsurance brokers; and the Financial
Ombudsman Service, or as required by law (for a full list see Calliden’s
and Dawes’ Privacy Policy). In the event of a claim, Calliden and Dawes
may disclose your personal information (including sensitive information) to
overseas reinsurers for the purpose of assessing your claim. Calliden and
Dawes will only share information with third parties where Calliden and
Dawes reasonably believe it is necessary in assessing your insurance claim
and in providing the products and services requested.
Calliden’s and Dawes’ Privacy Policy contains information about how to
access and correct the personal information about you and also how to
complain about a breach of privacy. If you would like additional information
about privacy or would like to obtain a copy of the Privacy Policy, please
contact Calliden’s Privacy Officer by:
• Tel: 1300 00 2255
• Fax: 1300 662 215
• Email: [email protected]
• Mail: Privacy Officer, PO Box 348, Milsons Point NSW 1565.
You can download a copy of Calliden’s and Dawes’ Privacy Policy by
visiting www.calliden.com.au/docs/PrivacyPolicy.pdf
Unusual Terms
The policy you are applying for contains what may be considered unusual
terms. These are listed in the Product Disclosure Statement (PDS). We
strongly recommend that you read the PDS and the entire Policy Wording
to make yourself familiar with all the terms and conditions of the policy.
All questions must be answered in full. If there is insufficient space
to fully answer any question, please attach a separate sheet of
paper. If you are unsure how to answer any questions, please
contact your insurance adviser.
DAWES DIRT BIKE INSURANCE APPLICATION FORM - CMDAW DB APP 1114
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Dirt Bike Insurance Application PERIOD OF
INSURANCE
From
to
THE INSURED
Full Name of Insured:
at 4.00 P.M Local standard time
Phone:
Insured’s Postal Address:
Postcode:
Name of any other interested party:
i.e. bank or finance company
DETAILS OF BIKES
Year, Make & Model
Engine Number
Frame/VIN Number
Purchase Date
Purchase Price
Sum Insured*
/
/
$
$
/
/
$
$
/
/
$
$
/
/
$
$ *The sum insured should be the current market value
DETAILS OF
STORAGE
Total
Address where bikes are
normally stored overnight:
Garage
Communal Parking Area
$
Postcode:
Driveway, front or backyard of usual overnight parking address listed above Other (please specify)
Are the items left in or on a Motorcycle overnight when not at the usual place of storage?
If yes, please specify what security measures are taken:
YES
NO
HISTORY OF
INSURED
Have you or any of the named riders in the last 5 years had a vehicle and/or motorcycle accident
or loss or made a claim under a motor vehicle and/or motorcycle insurance policy.
YESNO
If Yes, please give details
Had a motorcycle stolen and/or burnt?
If Yes, please give details
Has any insurer declined insurance or imposed any special conditions?
If Yes, please give details
Have you or any person covered by this insurance been convicted of
any criminal charges in the last five years
If Yes, please give details
DAWES DIRT BIKE INSURANCE APPLICATION FORM - CMDAW DB APP 1114 YESNO
YES
NO
YES
NO
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DECLARATION BY THE
INSURED:
I/we declare that:
• The Duty of Disclosure and Privacy statement incorporated in this application has been read and understood by me/us.
• All answers and statements made in this application are true, complete and correct and that no information has been
withheld.
• I/we have read and understood the application and policy.
• I/we understand that the “Notes” in this application are for my/our assistance, but I/we must read the Product
Disclosure Statement and Policy Wording for full details of all policy terms, conditions and exclusions.
• I/we acknowledge Dawes Underwriting Australia Pty Ltd t/as Dawes Motor Insurance may give to, and obtain from,
other insurers and/or insurance/financial reference bureau, parts or service providers, personal information relating to
this application and/or policy as well as insurance claims information obtained during the currency of this policy.
• I/we understand that all drivers must be declared, otherwise cover will not apply.
• I/we understand that if I/we have elected to reduce the premium payable for this policy due to a restricted use of the
Motorcycle, I/we must comply with the usage restrictions or the Motorcycle will not be insured.
• The answers provided are true, complete & correct on behalf of all persons to be insured.
• I/we have received or downloaded from the internet the Financial Services Guide, Product Disclosure Statement and Policy Wording.
• Before completing this application form, I/we have read and understood the Financial Services Guide, Product Disclosure Statement and Policy Wording.
Signed: Date:
APPLICATION RETURN:
/
/
You can return the completed application form to us in the following ways:
Post:
PO Box 348
Milsons Point NSW 1565
Fax:
1300 662 215
E-mail:
[email protected]
Dawes Underwriting Australia Pty Ltd
trading as Dawes Motor Insurance
PO Box 348 Milsons Point NSW 1565
The product is underwritten by Calliden Insurance Limited (ABN 47 004 125 268, AFSL 234438)
DAWES DIRT BIKE INSURANCE APPLICATION FORM - CMDAW DB APP 1114 Tel: 1300 188 299
Fax: 1300 662 215
ABN: 18 050 289 506
AR No. 342982
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