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

Your duty to take reasonable care not to make a misrepresentation Your application for insurance cover will be treated as if You are applying for a ‘consumer insurance contract’. Before the contract of insurance is entered into, You have a legal duty to take reasonable care not to make a misrepresentation to the insurer under the Insurance Contracts Act 1984 (Cth). It is very important that You comply with Your duty, as this may impact on Your insurance cover.

A misrepresentation is an answer or statement that is not true, only partially true, or does not fairly reflect the truth.

When You apply for insurance, We will ask You clear and specific questions that are relevant to Our decision to insure You. Your answers in response to Our questions are important as We use them to determine whether We can provide insurance cover to You, and if so, the terms of the Policy and the premium We will charge. This means that when answering Our questions, You should respond fully, honestly and accurately.

The duty to take reasonable care not to make a misrepresentation applies anytime You answer Our questions as a part of an initial insurance application, when extending or making changes to an existing insurance, and reinstating any previous contract of insurance.

We may later investigate the answers You provide to Us, for example, when a claim is made.

Guidance for answering Our questions:

Important: please ensure that You take care when providing Your answers in response to Our questions in relation to Your insurance application. You should respond fully, honestly and accurately. If You do not, it may affect Your insurance cover.

When answering Our questions, please:

Think carefully about Your responses. If You do not understand the question or require further explanation, please ask Us before responding;
Make sure Your responses are truthful, accurate and complete answers to every question that We ask You;
Provide Us with all relevant information in response to Our questions. If You are unsure what information to include, please include it or check with Us, Your broker or adviser;
Do not assume that We will contact anyone else for the information We are asking You for;
Review each answer You have provided on Your insurance application carefully and make any corrections (if necessary) before submitting it to Us. You are responsible for the answers that You provide Us, even if You have had help in preparing Your application, for example from Your broker, intermediary, advisor or someone else.

Before Your insurance cover starts, please tell Us of any changes that may be required to the answers You have given to Our questions. This may save time as any changes may require further investigation or assessment of the risk.

If, after Your insurance cover starts, You think You may not have complied with Your duty, please contact Us, Your broker or advisor immediately and We will let You know whether it has any impact on Your cover.

We may contact You after You have submitted Your application to clarify or collect any information that You may not have included. The information You provide may be recorded and used by Us in assessing Your application. Your duty to take reasonable care not to make a misrepresentation applies to all types of communication with Us, including written, electronic, online, when speaking with Us in person or on the telephone, or a mix of these.

If You do not comply with Your duty

If You do not take reasonable care not to make a misrepresentation, it may have serious consequences for Your insurance. If You have failed to comply with Your duty, We have certain rights, which may depend on what Your insurance offer may have been had You not made a misrepresentation, and whether or not the misrepresentation was fraudulent. We have different actions available to Us, for example, We may do one of the following:

Avoid Your insurance cover. This means that Your insurance contract and cover will be treated as if it never existed;
Change the amount of cover, for example the level of cover may be reduced;
Change the terms of Your insurance contract, for example certain events may be excluded from being covered.

This may mean an insurance claim may not be paid, or the amount or benefit paid may be reduced, or premiums increased.

If We suspect that You may have breached Your duty to take reasonable care not to make a misrepresentation, before We exercise any of the actions available to Us, We will:

Explain Our reasons why We believe You have breached Your duty; and
Provide You with an opportunity to respond and provide Us with further information.

If We decide to make changes to Your cover, We will notify You of Our decision and provide You with the review process and complaints procedure to follow if You disagree with Our decision.

If You need help

It is very important that You understand this information, the questions that We ask You and Your duty. If You are having difficulty for any reason, such as a disability, English language, or require further support such as a support person You trust, please contact Us so that We may tell You how We may assist in providing additional support.

If You have any questions, please contact Us, Your broker or advisor.

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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