General & Products & Liability - Individuals - Proposal

The Proposer

Insured (Your) Name
Business/Trading Name
Email
Phone

Have you been referred by Private Escort Finder?

Yes   
No   

Are You registered for GST purposes?

Yes   
No   
ABN

Policy Start Date

From

General Information

a) In the last five(5) years have you suffered any loss or damage which would have been covered by the proposed insurance policy?
Yes   
No   
b) Have you ever been convicted of any criminal offence or served a prison sentence?
Yes   
No   
c) Do you use fire or water in your act?
Yes   
No   
If you answered YES to any question above, provide full details in the space below
This Policy is only for individuals and sole operators. Please select your occupation/s below
(a) Escort
Yes   
(b) Exotic Dancer
Yes   
(c) Stripper
Yes   
(d) Sex worker
Yes   
Limit of Indemnity Required:
$10,000,000   
Premium $350
$20,000,000   
Premium $450

Important Notices

Your Duty of Disclosure
This policy is subject to The Insurance Contracts Act 1984. Under that Act You have a Duty of Disclosure.
This means:
1 When You ask for cover, You must tell Us all that You know about the risk that You want covered which may affect Our decision:
   a   To offer You cover, and
   b   The terms and the cost of such cover.
2 If You ask for the cover to be renewed, extended, altered or reinstated You must tell Us:
   a   If there have been any changes in what is covered, and
   b   Of all things that may increase the chances of a claim.

What You Don't Have to Tell Us
You do not have to tell Us of anything;
1   That reduces the chances of a claim. But, if You do, it may let Us offer You better terms.
2   That is common knowledge.
3   That we should know as a normal part of Our business.
4   If We waive Your Duty of Disclosure.

Non-Disclosure
If You don't tell Us something that You know which may affect Our decision to offer You cover or the terms of that cover We may be allowed to:
1 Reduce the amount that We have to pay for a claim. This may mean that We would pay You nothing.
Cancel this policy. We may even be allowed to cancel this policy from the date that the cover started if You lie to Us or deliberately keep information from Us or mislead Us.

Declaration

     
I hereby declare that All the information provided in this Proposal is correct and I have read the above Important Notices and understood and complied with the Duty of Disclosure.
Name
Date
17-11-2018