B ro a d a c re C ro p I n s u r a n c e P ro p o s a l Season 2008-2009
If you only require a quotation please tick this box
Please print clearly in BLOCK LETTERS. If there is insufficient space to answer any questions attach a separate page.
Details of Applicant
Insured Name ……………………………..……………………………………..……………………… ABN ………………………………..…. Contact Name ………………………………………………………………………………………..……………………………………………… Mailing Address…………………………..………………………… ………………………Town ……………………………………………….. Post Code………………… Daytime Contact No ……………………………………Fax No ……………………………………………...…… Mobile/UHF No ……………………………………………Email Address ……………………………………..……………………………..…. Have you ever had any insurance policy declined or cancelled, a renewal refused or had a claim rejected? (Please circle) Yes No
If Yes, which year …………………………………..Name of Insurer……………………………………………………………………………
Details of Property
Farm Name …………………………………………………………………………………………………………………………………..……… Address ...…………………………………………………………………………………………………………………………………….……… Town …………………………………………………………………………………State ………………………Post Code…………..……….. Direction from Town ……………………………………………………… Distance (km) …………………………………………….………… Shire/Hundred (SA) ………………………………………………Sub-Shire (Intermediary use)…………………………………………….
Details of Other Interested Parties - Sharefarmers, Financiers
Are any of your crops sharefarmed? (Please circle) Yes No If Yes, please complete Sharefarmer details below.
Sharefarmer’s Name ……………………………………………………..……………………………………Share (%) ……………………… Address …………………………………………………….………………………………………………………………………………………… Town ……………………………………………………………..……………………… State……….……………… Post Code……………… Please provide details of any other party who has a registered financial interest in your crop. Financier’s Name………………………………………………………………..………………………Interest(%) …………………………… Cover Required (Please circle) Hail & Fire Hail Only Fire Only
Excess
Do you wish to take the Reducing Excess option? (Extra premium applies) (Please circle) Do you wish to reduce your premium by taking a higher excess? (Please circle) Yes No Yes No
If Yes, please circle the amount of the increase you wish to take in addition to the standard per paddock excess 5% 10% 15% 20%
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Agricola Broadacre Crop Insurance Proposal Form
Farm Name……………………………………………………………….Shire……………………………………………………………... Crop Details
Please check your crops are itemised correctly into clearly identifiable paddocks, as the Hail Excess is applied to each paddock.
Paddock Name
Crop Type (eg Wheat)
Area (Ha) A
Yield (T/ha) B
Agreed Values ($/t) C
Insured Share (%) D
Sum Insured $ E=(AXBXCXD)
Excess (%)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Total Area Total Sum Insured
Summer Crop Only - Expected Harvest Date ……/……/…….. Notes
1. 2. 3. Yield (Column B) – Please specify your estimated potential yield. This can be adjusted prior to the Final Reduction Date. Agreed Value (Column C) - You must provide an agreed value per tonne for every crop insured. This can be adjusted prior to the Final Reduction Date. The values must be ‘farm gate’ values, excluding GST and costs such as freight, storage, bulk handling and industry levies. If you do not cover all of your crops, you must provide a Property map which clearly identifies all insured and uninsured crops and shows the direction of North.
Declaration
I / We (the applicant) agree that when I/we sign and submit this proposal, cover is bound when this proposal is accepted by Agricola, and that the cover cannot be cancelled (except in special circumstances) and I/we agree to pay the premium applicable except if quotation box ticked; have read the Statutory Notices and the Important Notices in relation to this Insurance Cover, on page 3 of this proposal; understand the situations in which cover is limited or excluded; have disclosed everything likely to affect the acceptance of this proposal; declare that answers and statements made in this proposal are correct; and declare the crops the subject of this insurance are free from any existing hail or other insurable damage.
Applicant’s signature……………………………………………………………………………………Date of signing ……./……../……..
Intermediary Details Intermediary……………………………………………………………………Branch…………………………………./…………………………...… Contact Person ……………………………………………………………… Contact no……………………………………………………………….
Agricola Broadacre Crop Insurance Proposal Form 05/08 Page 2 of 3
IMPORTANT CUSTOMER INFORMATION Please read the policy carefully and do not hesitate to contact your intermediary if you are uncertain of any aspect.
The following Statutory Notices are drawn to your attention in accordance with the provisions of the Insurance Contracts Act 1984 (cth), as amended. enable us to develop terms of insurance for you to consider.
Your privacy
We are bound by the National Privacy Principles of the Privacy Act 1988 when we collect and handle your personal information. The Personal information we collect in connection with this insurance is needed to enable us to evaluate your application and to administer your insurance cover. You may request us to provide you with a copy of that information, except information that has been provided to us in confidence. We are entitled to disclose your personal information to other persons, such as our insurers, reinsurers, loss assessors and claims consultants.
Your duty of disclosure
Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer's decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty, however, does not require disclosure of any matter: that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that the insurer knows or, in the ordinary course of his business, ought to know; or as to which compliance with your duty is waived by the insurer.
Non disclosure
If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce his 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.
48 hour Delay Period and Date of Acceptance
Cover under this policy commences 48 hours after 4.00pm on the date we accept your crop insurance proposal.
Not a renewable policy
This policy ends when the period of the policy ends. Because of changes in crop types and areas sown from year to year, this is not a policy of a kind that it is usual to renew or for the renewal of which it is usual to negotiate. If you wish to arrange similar insurance with us for your crop in the next growing season, you will have to complete a new crop insurance proposal form to
Existing Crop Damage
If your crop has been damaged this season by an insured peril, you must tell us. We will then arrange to have your crop inspected by a loss adjuster, at your cost, before your proposal will be considered.
Cover developed and managed by Agricola Underwriting Management Pty Ltd acting as agent of Wesfarmers General Insurance Limited, trading as Lumley General ABN 24 000 036 279 & AFS Licence 241461, Level 9, 309 Kent St, Sydney, NSW 2000. Agricola Crop Insurance is the registered business name of Agricola Underwriting Managment Pty Limited ABN 87 070 058 212 AFS Licnece 237271 Level 6, North Tower, 459 Collins Street Melbourne Victoria 3000 Telephone +61 3 9603 1050 Facsimile +61 3 9620 1222 Email: broadacre@agricola.com.au Website: www.agricola.com.au
Agricola Broadacre Crop Insurance Proposal Form
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