APF Equipment Insurance Individual Member Proposal Form

Proposer Details

First Name *

Last Name *

APF Number *

Date of Birth *

Physical address where gear is kept: *

Post Code *

Postal address (if different from physical address)

Telephone (Home)

Telephone (Mobile) *

Email Address *

Period of Insurance Required

Existing Policy Renewal

New Application

Proposed Policy Inception Date *

Endorsement to Existing Policy

Endorsement date required

Details of Equipment to be Insured

Gear Type

Make *

Serial Number *

Age (Years) *

Description *

Insured Amount *

Please attach photos of gear to be insured

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Yes, please provide me with 60 days per annum International Cover at an additional cost of AUD50.00

Is any of the insured equipment hired from a third party *

YesNo

If equipment is hired then please provide details of owners

Insurance and Claims History

Has any insurer ever declined to issue insurance to You or any person to be covered by this insurance? *

YesNoNot Applicable - Current policy with ATC

If "Yes" to the above, please provide full details

In the past five years, have you made any claim under any of the insurances applied for as part of this application or suffered any insured or uninsured loss or damage which would be covered by the insurance being applied for? *

YesNoNot Applicable - Current policy with ATC

If "Yes" to the above, please provide full details.

Please attach claims history from current or previous insurer(s) if available (Not applicable if current policy with ATC).

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Important Notices

Coverage is within Australia (and its territories) only.
International coverage is available for a maximium of 60 days per annum (If selected).
Proof of ownership is required in event of a claim so please retain any invoices and receipts etc.
Please attach digital pictures of your equipment if possible.
This policy has been arranged by Insuranet and this product is administered by ATC Insurance Solutions Pty Ltd ABN 25 121 360 978 AFSL 305802 of Level 4, 451 Little Bourke Street, Melbourne VIC 3000 under an authority from certain Underwriters at Lloyd’s.
The full Product Disclosure Statement and Policy Wording (click below to view a copy). Please ensure you have read and understood the Product Disclosure Statement and Policy Wording.

View a copy of the Product Disclosure Statement here

Duty of Disclosure

Before You take out an insurance policy with Us, the Insurance Contracts Act 1984 (Cth) requires You to tell Us every matter that is known to You that:

You know to be a matter relevant to Our decision whether to accept the risk and, if so, on what terms, or
a reasonable person in the circumstances could be expected to know to be a matter relevant to Our decision. Therefore, before You enter (or renew, extend, vary or reinstate) an insurance policy with Us, You must:
give Us complete and honest answers
tell Us everything You know, and
tell Us everything that a reasonable person in the circumstances could be expected to know.

Who needs to disclose?

You are answering questions on behalf of anyone You want to be covered by this insurance. The duty of disclosure applies to You and everyone else insured by the Policy.

How long does the duty of disclosure last?

The duty to disclose continues right up to the commencement date or renewal date of the insurance.

What We do not need to be told

You do not need to tell Us about any matter that:

diminishes Our risk
is of common knowledge
We know or, in the ordinary course of business, ought to know or
We say We do not need to know.

Failure to disclose

We can reduce the amount We pay under this insurance for a claim or even cancel the insurance cover if You, or anyone else insured under the Policy, fail to comply with the duty of disclosure. If a non-disclosure is fraudulent, We may avoid the Policy under the Insurance Contracts Act 1984 (Cth), resulting in Us treating the Policy as if it never existed.

Under insurance

This means that if You under insure, You may be required to bear a portion of the loss.

Inadequate space to answer

If there is inadequate space to answer any questions or You need to disclose something to Us because of Your duty of disclosure, please attach a separate piece of paper to this proposal form providing full details.

Privacy Act

In this statement “we”, “us” and “our” means Lloyd’s and ATC Insurance Solutions (ATC) as its agent.

We are bound by the requirements of the Privacy Act 1988 (Cth), the Privacy Amendment (Private Sector) Act 2000 (Cth) and the Privacy Amendment (Enhancing Privacy Protection) Act 2012. This sets out standards on the collection, use, disclosure and handling of personal information.

Our Privacy Policy is available at www.atcis.com.au or by calling us on the number below.

We, and our agents, need to collect, use and disclose your personal information in order to consider your application for insurance and to provide the cover you have chosen, administer the insurance and assess any claim. You can choose not to provide us with some of the details or all of your personal information, but this may affect our ability to provide the cover, administer the insurance or assess a claim.

We may disclose your personal information to third parties (and/or collect additional personal information about you from them) who assist us in providing the above services and some of these are likely to be overseas recipients in the United Kingdom.

These parties which include our related entities, distributors, agents, insurers, claims investigators, assessors, lawyers, medical practitioners and health workers, and federal or state regulatory authorities, including Medicare Australia and Centrelink will only use the personal information for the purposes we provided it to them for (unless otherwise required by law).

Information will be obtained from individuals directly where possible and practicable to do so. Sometimes it may be collected indirectly (e.g. from your representatives or co-insureds). If you provide information for another person you represent to us that:

you have the authority from them to do so and it is as if they provided it to us;
you have made them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it.
If it is sensitive information we rely on you to have obtained their consent on these matters. If you have not done or will not do either of these things, you must tell us before you provide the relevant information.

You are entitled to access your information and request correction if required. You may also opt out of receiving materials sent by us by contacting ATC on (03) 9258 1700 or write to us at the address given on page 1.

Declaration

I/We represent that the above statements and facts are true and that no material facts have been suppressed or misstated. Furthermore, I/We:

have either completed all the questions on this form personally or they have been completed by someone else on my/ our behalf and the answers have been checked for fullness and accuracy by me/us; *

have read and understood the information concerning the duty of disclosure and all other important notices; *

agree to ATC Insurance Solutions obtaining from my/our previous insurer(s) any information it may need about my/our claims or insurance history; *

agree to ATC Insurance Solutions making enquiries from any third party to verify my/our claims history and other information disclosed herein or statements made by myself/ourselves in making this application; *

agree to ATC Insurance Solutions disclosing to any insurance intermediary appointed or to any former or future insurer of myself/ ourselves the claims history or any other information as may be determined; *

have reviewed and read a full copy of the Product Disclosure Statement and Policy Wording for this insurance. *

Signature of Proposer *

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