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Trades - Accident + Sickness Insurance

Please fill in all "Mandatory Field" sections and provide as many details as possible to speed up the processing of your request. You will receive a reply within two business working days!!

First Name:
  *
Last Name:
  *
Phone:
  *
Mobile:
Fax:
Email:
  *
Street Address:
  *
Suburb:
  *
Post Code:
  *
State:
  *
ABN Number:
Type of Trade:
  *
How long have you been working in this Trade for?:
  *
( Months / Years )
Trade License Number:
  *
Trade License Expiry Date:
  *
Date of Birth:
  *
Employment Status:
  *
Approx. Gross Weekly Earnings ($):
  *
Preferred waiting period before receiving benefit:
  *
Insurance Commencement:
  *
When would you like the 12 month policy to commence?
Have you had any Insurance cover declined or cancelled?:
  *
If Yes, please provide details why:
Have you made any Insurance claims in the last 12 months?:
  *
If Yes, please provide details of claims:
Have you had any criminal offences or convictions in the last 5 years?:
  *
If Yes, please provide details of previous criminal history:
Have you ever been declared Bankrupt?:
  *
If Yes, please provide details of bankruptcy:
Have you ever been involved in a Company or Business that went into liquidation or receivership?:
  *
If Yes to the above, please provide full details:
Help us help you by answering this survey question.
What type of roof do you have?:
  *
Prior to entering into a contract of general insurance you have a duty to disclose certain information. You have the same duty to disclose prior to renewing, extending or varying a general insurance contract. When answering the questions you must be honest and you have a duty under law to tell us anything known to you. You, and of which a reasonable person in the known circumstances would include in answer to the questions. We use the answers in deciding whether to insure you and on what terms. If you do not answer the questions in this way, we may reduce or refuse to pay a claim, or cancel the policy. If you answer questions fraudulently, we may refuse to pay a claim and treat the policy as never have been valid.
Declaration:
I / We confirm we have read the Duty of Disclosure included in this application form and confirm the answers are true correct and that no information has been withheld which may affect the decision to accept this application or the terms and conditions
  *
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