Insurance Declaration Form

Applicant details

First name*

Middle name

Surname*

Email*

Phone number*

Year of birth*

State*

Employer*

Vehicle details

Make*

Model*

Variant*

Year*

Modifications*

Has the vehicle been modified to enhance or impact its performance, for either off-road or on-road driving, by alteration to one or more of the:

engine (including upgrade to the engine control unit, fuel injectors or any other change which may alter the power produced by the engine);
suspension (including but not limited to lift kits, GVM upgrades and airbag suspension kits);
exhaust system;
air filters;
standard wheels or tyres by an increase of more than 1 inch;
wheelbase or chassis;
exterior body by addition of a body kit.

Yes

No

Unsure

Please list any changes or modifications to the vehicle:

If unsure, please list any changes or modifications to the vehicle of which you are aware:

Applicant and Driver(s) History

In the last 3 years have you or any intended driver of this car:

a) had an application for, or contract of, motor insurance refused, declined or cancelled?*

a) had an application for, or contract of, motor insurance refused, declined or cancelled?

Yes

No

Please provide details:*

Please provide details:

b) committed any driving offence(s) which resulted in the suspension, cancellation or restriction of a driver’s licence or permit?*

b) committed any driving offence(s) which resulted in the suspension, cancellation or restriction of a driver’s licence or permit?

Yes

No

Please provide details:*

Please provide details:

c) made more than 3 motor vehicle claims where you (or the intended driver) had to pay an excess?*

c) made more than 3 motor vehicle claims where you (or the intended driver) had to pay an excess?

Yes

No

Please provide details:*

Please provide details:

d) had any criminal convictions (or pending prosecutions) related to fraud, theft, burglary, dishonesty, arson, criminal damage, malicious damage or wilful damage?*

d) had any criminal convictions (or pending prosecutions) related to fraud, theft, burglary, dishonesty, arson, criminal damage, malicious damage or wilful damage?

Yes

No

Please provide details:*

Please provide details:

Please note that if your response is ‘Yes’ to any of the above questions, you may not be eligible for cover under Paywise’s Novated Comprehensive Motor Insurance policy.

Declarations

In acquiring or applying to acquire this product, I declare that:

Declaration 1*

the information I have given is honest, correct and complete and I understand that the decision of the issuer of the product to provide cover is based on this information; and

Declaration 2*

I understand it is important that I read and understand the terms and conditions set out in the Product Disclosure Statement in relation to the product.

Declaration 3*

I acknowledge that my personal information is collected so that Paywise can:

provide an insurance quote based on my individual profile; and
use it for any other purpose as specified in the Paywise Privacy Policy.

Duty of disclosure

Before the Policyholder enters into or renews the policy, the Policyholder has a duty to disclose to the insurer every matter that the Policyholder knows, or could reasonably be expected to know, that is relevant to the insurer’s decision whether to insure the Policyholder and anyone else to be insured under this policy, and on what terms. This duty applies at inception of the policy, throughout the Period Of Cover and at renewal.

It is a condition of provision of cover in respect of a Lessee under the policy that the insurer obtains from the Policyholder the agreed information about each Lessee in the form it makes available before cover to that Lessee is provided, and the insurer may not be liable to provide or to pay benefits where there has been misrepresentation or non-disclosure about a Lessee.

For these purposes the insurer will treat a Lessee as if they did owe a duty of disclosure to the insurer and without limitation will exercise any powers in respect of non-payment of benefits or cancellation of cover which the insurer could exercise under the Insurance Contracts Act 1984 (Cth) if a Lessee did owe the insurer a duty of disclosure.

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 Paywise.

I accept the above duty of disclosure*

I accept the above duty of disclosure

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