Downunder Insurance - Motorhome Insurance Enquiry Form

Downunder Insurance - Motorhome Insurance Enquiry Form

Please provide us with as much information as possible to assist us in helping you with your enquiry.
However only items marked with (*) are required, once we have this information one of our representatives will contact you to assist with your enquiry.

Last Name (*)

First Name (*)

Address 1

Address 2

SUBURB (*)

STATE (*)

Postcode (*)

Contact Telephone (*)

Alternative Telephone

Facsimile (if available)

E-mail (*)

How should we contact you?

E-mailPhoneMail

Motorhome Type

Year Built

Gross Vehicle Mass

# Years Lic for this vehicle

Registration Number

Vin Number

Serial Number

Date of Birth

Name of Financier

Amount Insured

Accessories Amount Insured

List Accessories

Did you buy your Motor Home new?

Year of Purchase?

Purchase Price

Description of Trailer

Value of Trailer?

Annexe Sum Insured

Contents Limit

Portable Personal Valuables

Portable Personal Valuables Description

No Claims Bonus Years if applicable

Questions Section

Has any insurer declined to insure you?

NoYes

Has any insurer declined to renew a policy?

NoYes

Have you ever been charged with insurance fraud?

NoYes

Are you an undischarged bankrupt?

NoYes

Have special conditions ever been set on a policy?

NoYes

Has an increased excess ever been imposed

NoYes

Have you had any prior claims rejected?

NoYes

Details if YES to above

Tell us of any criminal charges

Who is your current insurer?

Policy Number

Will you be claiming a GST Input Tax credit?

NoYes

If so what % of GST will you claim as ITC?

How did you find us

# of Motor vehicle accidents you have had in last 5 years

# of Motor vehicle fines you have had in last 5 years

Have you ever had your driver's license or permit…(please tick most appropriate)

CancelledReduced to a lessor gradeSpecial ConditionsSuspended

Accident and Fines Details

How many motor vehicle claims you have had in last 5 years

Claim Details

Name of Insurer

Will anyone under the age of 25 drive the vehicle?

YesNo

Age of youngest driver

Privacy Statement

Manufactured Homes Insurance Agency Pty Ltd (MHIA) and its underwriters and representatives are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Private Sector Act 2000 (the Act)).  This sets out basic standards relating to the collection, use, disclosure and handling of personal information.

"Personal information" is essentially information or an opinion about a living individual whose identity is apparent or can reasonably be ascertained from the information or opinion.

Information will be obtained from individuals directly where possible.  Sometimes it may be collected indirectly.

Only information necessary for the arrangement and administration of MHIA's business by MHIA and its underwriters and representatives will be collected.  This includes information necessary to accept the risk, to assess a claim and to determine competitive and appropriate premiums.  We will only ask for and take into account relevant information.

MHIA and its underwriters or representatives disclose personal information to third parties who they believe are necessary to assist them in doing the above.  These parties will only use the personal information for the purposes we provided it (or if required by law).

When you give MHIA and its underwriters or representatives personal information about other individuals, we rely on you to have made or make 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, before supplying us with the relevant information.

You are entitled to access information about you that we have relied on in making decisions that concern your insurance with us.  You will also have the opportunity to correct any mistakes or inaccuracies in the information we hold about you.  In special circumstances, we may decline to release information but we will not do so unreasonably.  Special circumstances may include, but are not limited to, information that is subject to privacy laws, information that is protected from disclosure by law, or where the release of the information may be prejudicial to us in relation to a dispute about your insurance.  Where we decline to release information, we will give you reasons and you will have the right to request us to review our decision through our complaints handling procedures.  We will provide our reasons in writing upon request.

Finally, you may also opt out of receiving materials sent by MHIA by contacting our office on (02) 4303 0300.  For the full text of our Privacy Policy, contact our office or refer to our website at http://www.mhia.com.au

(*)

I have read understand and agree with the MHIA privacy statement.

Downunder Insurance - Motorhome Insurance Enquiry Form

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