One Underwriting - On Track Motor Racing Insurance Proposal

On Track Motor Racing Insurance Proposal

Important Information : Your Declaration & Statement of Facts Held

The answers contained in this form are a record of the information You have provided Us. In accepting Our offer of insurance, this Statement of Facts is Your completed Proposal Form, which You will be bound by until such time as it is replaced by a new Statement of Facts or Proposal Form and agreed to by Us in writing. We remind You of Your Duty to take Reasonable Care not to Misrepresent when entering into a contract of insurance, the full definition of the Your Duty to take Reasonable Care not to Misrepresent can be found in the Important Conditions at the end of this document. Your answers are extremely important and in conjunction with the Terms, Conditions, Limitations and Exclusions form part of Your contract with Us.

If We issue You a Policy Schedule and any of the information provided is not complete or incorrect in any way, please advise Us immediately. Any amendments to cover must be agreed to by Us, in writing. Brokers - Any closing instructions that We receive do not supercede this Policy Schedule of cover.

Supplementary Product Disclosure Statement

This document is also a Supplementary Product Disclosure Statement (SPDS) which updates the Insurer’s PDS - for details of the PDS see the Product Disclosure Statement and Policy Wording. You should read the SPDS together with the PDS and Policy Wording and any other SPDS the Insurer may provide before entering into any contract of insurance.

Broker or dealer details
Company:
Name:
Phone:
Email:
General
Insured Name(s): (Policy holder and payee in the event of a claim):
Contact Name:
Postal Address:
Telephone No:
Mobile No:
Email:
Website:
Insured Vehicle
Year:
Model:
Make:
VIN / Chassis No.:
Registration No.:	If registered
Is the Vehicle Registered?	Yes No
Is the Vehicle financed?	Yes No
Finance Company Name:
Amount Owing:
No. of Years you have owned this vehicle?:
Are you the legal owner of this vehicle?	Yes No If no, please provide full details in the additional notes.
Vehicle Value:	Value of complete car
Value less Engine and Gearbox:	Not applicable if standard production vehicle
Accessories:
Modifications:
Sum Insured:
Drivers to be covered and experience
Driver (1) Name:
Date of Birth:
Holder of an Australian Driver’s Licence?	Yes No
Number of Years Australian Driver’s Licence Held?:
Are you a Confederation of Australian Motorsports (CAMS) Member?	Yes No
CAMS Member/Licence Number:
Previous On Track and Competition Experience	Please include category type(s) and year(s) and/or number of event days of participation if applicable
Accident History: (Please attach separate page if insufficient space)	Please list all insured or uninsured on-track incidents resulting in fire and/or impact damage whether at fault or not
Drivers to be covered and experience
Driver (2) Name:
Date of Birth:
Holder of an Australian Driver’s Licence?	Yes No
Number of Years Australian Driver’s Licence Held?:
Are you a Confederation of Australian Motorsports (CAMS) Member?	Yes No
CAMS Member/Licence Number:
Previous On Track and Competition Experience	Please include category type(s) and year(s) and/or number of event days of participation if applicable
Accident History: (Please attach separate page if insufficient space)	Please list all insured or uninsured on-track incidents resulting in fire and/or impact damage whether at fault or not
Schedule of Events Requiring Insurance
Name of Event:
Race Series:
Driver Training Day:
Qualified Training Instructor Present?	Yes No Unknown If yes, provide the details
Will the Instruction will one on one or Group Training?	One on one Group Unknown
Event Organiser:
Is the event affiliated to a Governing Body, e.g. CAMS, if so list
Circuit:
Date of Event ( If multiple days, list all days):
Does the event have a website?	Yes No If yes, write it down
No. of Race Meetings:
No. of Test Days:
Will there be other vehicles on Track at the same time?	Yes No
Will the Event be Competitive (i.e. timed or place getting)?	Yes No
Notes and Additional Information
Declaration I / We agree on my own behalf and on behalf of all other insured persons that: the within statements are true. The Duty of Disclosure has been complied with. The Vehicle described is and shall be maintained in an appropriate condition. When signing the Proposal/Quotation Form, I/We acknowledge that should some or all of the answers stated in this form NOT be in my/our own handwriting, the answers have been checked and I/We certify they are correct and that I/We agree to accept a Policy subject to the terms, exceptions and conditions prescribed therein. The Vehicle to be Insured shall not be driven by any person other than an Authorised Driver or an Excepted Person or as otherwise endorsed to Your Policy Schedule. The Vehicle to be Insured shall not be driven by any person who to my/our knowledge has been refused any motor insurance or the continuance thereof. The Product Disclosure Statement (PDS) for this policy may be made available as described in the “Our Product Disclosure Statement’ notice. I/We have read and agree to the terms of the Privacy Notice.
Applicant’s name:
Applicant’s Signature
Date:	Today
Important notices This Insurance is underwritten by HDI Global Specialty SE - Australia, (ABN 58 129 395 544, AFS Licence number 458776), with its registered address at Tower 1, Level 33, 100 Barangaroo Avenue, Sydney NSW, 2000. Telephone (02) 8373 7580. One Underwriting acts as an agent of HDI Global Specialty SE - Australia in arranging and entering into this motor insurance, not the Insured. This quotation is valid only for a period of thirty (30) days and may be withdrawn or varied at any time by Us. By submitting the request for quotation You confirm that You have read and agree to the terms of the Privacy Notice and Terms of Business sent to You by Us. In submitting this information You are acting as agent of the proposed insured(s) and are doing so on their behalf. Our Product Disclosure Statement The law requires that you receive a “Product Disclosure Statement” (PDS) prepared by HDI Global Specialty SE - Australia. The PDS aims to give You enough information to decide whether to buy this product. The PDS is made up of a number of documents. The Proposal (or electronic declaration) and the PDS and Policy Wording contains the standard terms and conditions of cover. If cover is issued, the Policy Schedule other documents We tell You are included, will update and becomes part of the PDS. These documents are available to You (if You or Your agent does not already have them, by calling Us, visiting our office or website: oneunderwriting.com.au) 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. For example this will include You or any other persons to be covered under this Policy and their driving record, claims (or incidents unclaimed or uninsured for), criminal and insurance history. This duty also extends to, but not limited to how Your Vehicle is Garaged, registered or used in frequency and nature of use for example Private Use, Business Use or otherwise. To assist You with providing Us with honest and accurate responses to any questions We ask of You, We have endeavored 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). Short Form Privacy Disclosure and Consent Application/ Claim Forms 1. One Underwriting Pty Ltd is committed to protecting Your personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). We collect, use and disclose personal information to offer, promote, provide, manage and administer Our various insurance services We are involved in as set out in the One Underwriting Privacy Notice. In order to do this, We may also share Your information with other persons or entities who assist Us in providing or promoting Our services as set out in the One Underwriting Privacy Notice. Further information about our privacy practices can be located in the One Underwriting Privacy Policy, a copy of which can also be sent to You on request by Your One Underwriting representative. You may also gain access to Your personal information, or modify Your privacy preferences, by contacting Your One Underwriting representative or Our Privacy Officer through the means set out in the One Underwriting Privacy Notice. 2. If You are disclosing personal or sensitive information about any other person to One Underwriting, You confirm that You have obtained the consent of that person to disclose to One Underwriting their personal or sensitive information and You have made them aware that One Underwriting will or may disclose their information to third parties that are reasonably necessary to assist in the provision of the relevant services or products. If You have not obtained consent from this other person to disclose their personal or sensitive information to One Underwriting, You will inform Us before providing the relevant information to Us. By submitting this Quotation & Proposal Securus Motor Insurance, You acknowledge that You have read the One Underwriting Privacy Notice and agree that We can handle any personal information You have provided to Us in the manner set out above.
I agree: Please check here if you accept. Unless You tick here, We or any of our group of companies may be in touch by any means (including email or SMS) at any time to let You know about goods, services or promotions that may be of interest to You

On Track Motor Racing Insurance Proposal

Important Information : Your Declaration & Statement of Facts Held

Supplementary Product Disclosure Statement

Declaration

Important notices

Your Duty to take Reasonable Care not to Misrepresent

Short Form Privacy Disclosure and Consent