Corporate Travel Insurance Application
Please answer all questions, if you have insufficient space please attach a separate sheet. Once complete please send to: Aussietravelcover Pty Ltd P.O. Box 495,(10/9 Bungan Street)Mona Vale,NSW 2103 Ph–612 9979 8888 or 1800 888 448 Fax–612 9997 1529 Email– sales@corporatetravelinsurance.com.au
DETAILS OF THE INSURED Insured Company Tax Status Address State Name Contact Person Fax No Email Phone No (Business) Postcode Registered Business Yes No ABN
Notices to Period of Cover required
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CORPORATE TRAVEL DETAILS Destinations Worldwide Europe Asia Pacific Australia No. of Employees ……….………………. Maximum No. of employees travelling together for any one trip .. …………………. Worldwide: Europe: Asia: Pacific: USA, Hawaii, Canada, Africa, Japan, China, Hong Kong, South America, Middle East, South Africa Europe, UK Asia SW Pacific, New Zealand, Papua New Guinea, Bali Number of Employees travelling per destination Total number of Employees trips Average duration per trip Days Days Days Days Days
CLAIMS HISTORY Have you previously been taken out Corporate Travel Insurance? If yes, please provide claims details Date of Claim Nature of Claim Yes No
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Amount of Claim .................................................................................... Have you ever had insurance declined or cancelled or special terms imposed by an Insurer? Yes No
If yes, please provide details ................................................................................................................................. .................................................................................................................................................................................. ..................................................................................................................................................................................
Aussietravelcover Corporate Travel Insurance is issued and underwritten by Allianz Australia Insurance Limited ABN 15 000 122 850 AFSL 234708
DUTY OF DISCLOSURE Before you enter into a contract of insurance with us, you have a duty under the law to disclose to us every matter that you know, or could reasonably be expected to know, is relevant to our decision whether to accept the risk and if so on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate this policy.
NON DISCLOSURE
If you do not tell us everything we need to know, we may reduce or refuse to pay a claim or cancel your policy. If you act fraudulently, we may treat the policy as having been void from its beginning. You don’t need to tell us anything which reduces the risk, is common knowledge, or that we already know, or ought to know in the ordinary course of our business; or we indicate we do not want to know. If you are not sure whether the information is important, then please disclose it to us.
PRIVACY Any personal information you provide is used by us and our agents to evaluate and arrange your policy and administer and provide the insurance services and manage your and our rights and obligations in relation to the insurance services, including managing, processing and investigating claims. If you provide us with personal information about someone else, we rely on you to tell them the purpose of such information and the use to which it will be used. DECLARATION AND SIGNATURE We acknowledge that a copy of the Combined Product Disclosure Statement and Policy Wording, which contains the Duty of Disclosure, was given to us before we applied for this insurance and that we have made this decision to purchase this insurance after carefully reading the policy and agree that this product is suitable for our needs. We understand that at the end of the period of insurance, should the travel days vary from the original estimated days, it will be necessary to adjust the premium. Any additional payments due to Aussietravelcover apply to both renewals and expired policies. Credits apply only to renewal policies, and will not exceed 20% of the total proposed premium. If the credit amount exceeds the premium payable for the renewal policy, the credit balance will be forfeited. Company Name Signature of Applicant Name of Applicant(s)
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Aussietravelcover Corporate Travel Insurance is issued and underwritten by Allianz Australia Insurance Limited ABN 15 000 122 850 AFSL 234708