"*" indicates required fields Step 1 of 4 25% Your DetailsName* First Last Address* Street Address Suburb State Postal Code Contact Number*Email* Period of InsuranceStart Date* DD slash MM slash YYYY Expiry Date* DD slash MM slash YYYY Insured Name* First Last ABN Trading Name Business Occupation Duty of DisclosureHave you ever or any partner(s) or director(s) of the business:Ever had an insurance policy cancelled, declined or terms imposed?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveEver been declared bankrupt?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveEver been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveBeen convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveBeen liable for any civil offence or pecuniary penalty (exceeding $5,000)?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveAny other matters you should disclose?*SelectYesNoDetails*Date of Incident (DD/MM/YYYY)Description Add RemoveDriver HistoryIn the last 3 years, has any person who is likely to drive the insured vehicles(s):Had any convictions or had any penalties imposed for driving under the influence of alcohol or drugs?*SelectYesNoDetails*YearDriver NameDetails (nature of offence, fine imposed) Add RemoveHad a drivers licence cancelled or suspended or restricted?*SelectYesNoDetails*YearDriver NameDetails (nature of offence, fine imposed) Add RemoveBeen convicted or charged with any driving offences or issued any speeding or traffic infringements (other than parking offences)?*SelectYesNoDetails*YearDriver Name Add RemoveHad any motor vehicle insurance refused?*SelectYesNoDetails*YearDriver NameDetails (nature of offence, fine imposed) Add RemoveClaimsIn the last 3 years, has any person who is likely to drive the insured vehicle(s):Had any Motor Vehicle claims?*SelectYesNoDetails*Date of LossClaim AmountDriver NameDescription & amount paid by insurer Add RemoveHad any insurer decline a claim?*SelectYesNoDetails*Date of LossClaim AmountDriver NameDescription & amount paid by insurer Add Remove Commercial Vehicles DetailsAdd Vehicle Year Make Model Actions Edit Delete There are no Vehicles. Add Vehicle Maximum number of vehicles reached. Driver DetailsDetails*First NameLast NameDate of Birth (DD/MM/YYYY)Age when driver licence was obtained Add RemoveConsent* I agreeNon Disclosure: If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. In addition to the above, following documents can be viewed on our website: PRIVACY POLICY: https://www.imcinsurance.com.au/privacy/ FINANCIAL SERVICES GUIDE (FSG): https://www.imcinsurance.com.au/financial-services-guide/ CONTACT US: IMC Insurance Brokers Pty Ltd | ABN 79 676 680 946 | AFSL 229344 Level 1 251-253 Malvern Road, South Yarra, VIC 3141 | 1300 251 253 | insure@imcinsurance.com.au Δ
