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Contact Details
Contact Person: First Name *
Contact Person: Last Name *
Email Address *
Best contact number *
Alternative Number (Work or Home)
The Insured
Tick if Contact Person
Insured Name *
Postal Address *
Suburb *
City / Town *
Post Code
Insured Policy Details
Name of Finance Company (if applicable)
On what date do you want cover to commence?*
Would you like a multi year policy*
24 Hour Roadside Assistance
Vehicle Details
Year*
Brands*
Vehicle Model*
Registration*
Value ($)*
Annual Mileage*
CC rating*
Vehicle first registered in
New/used*
New
Used
Exclude Drivers Under 25 Years*
Yes
No
If petrol powered, is it Turbocharged?*
Yes
No
Vehicle Location
Where the vehicle is kept *
Region *
Tick if same as Postal Address
Vehicle’s Street Address
Suburb
City/Town
Driver Details
Tick if Contact Person
Full Name of Main Driver*
Driver Occupation
Main driver date of birth*
Licence*
How long have you held this licence*
Other Drivers

Please list the full name, date of birth and % of use for any other intended drivers below

Name
date of birth
% Use
Licence
Occupation
Other Questions
Tick the relevant boxes below to answer yes if you or any intended drivers have ever been or had

been convicted drunk-in-charge (DIC) of a motor vehicle in the last 7 years?*
Yes
No
disqualified from holding a driver’s licence or had your licence suspended in the last 7 years, or are you aware of any circumstances where either of these is pending?*
Yes
No
fined or convicted for any criminal offence or traffic offence in the last 7 years, other than exceeding the speed limit or parking?*
Yes
No
ever had any insurance company at any time decline insurance for you, cancelled, or refused to renew any policy*
Yes
No
Excluding Glass, have you or any intended drivers had any vehicle insurance claims in the last 5 years?*
Nil
1 to 2 claims
3 or more claims
If you have answered YES to any of the above or have advised us of any previous claims please provide the details below
Payment Method
Payment Type:
Declaration

Terms and Conditions:

The following Terms and Conditions forms part of the application and is noted by the insured to have been read and accepted.  Please contact us urgently if there is anything you would like clarification on or do not agree with.

Insurer Financial Strength Rating:

Lloyd's has an A+ claims paying rating given by Standard & Poor's (Australia) Pty Limited on 26 September 2012.  Insurance companies (Rating and Inspections) Act 1994. Standard & Poor's (Australia) Pty Ltd give the following rating scale:


AAA

Extremely Strong

BBB

Good

CCC

Very Weak

AA

Very Strong

BB

Marginal

CC

Extremely Weak

A

Strong

B

Weak

R

Regulatory Action

Plus (+) or minus (-): The rating from 'AAA' to 'CCC' may be modified by the addition of a plus or minus sign to show relative standing within the major rating categories.

Pursuant to the Privacy Act 1993
On behalf of the Insured and any other person covered by this insurance.

  • I/we declare that all information contained in this insurance application and any attachments is complete and correct;
  • I/we have disclosed all information relevant to the acceptance of this proposal;
  • I/we agree that this proposal shall be the basis of the contract between me/us and the underwriter and also between me/us and  Platinum Auto Insurance Limited and the underwriting agent and I am/ We are willing to accept the terms, conditions and exclusions for these insurances;
  • The sum insured represents the full value of the property insured;
  • I/we understand that this proposal requests personal information about me/us which is held by, Lloyd's, their underwriting agents and Platinum Auto Insurance Limited to evaluate my/our application for insurance. Failure to provide the information sought may result in my/our application being declined or my/our insurance being void from the beginning;
  • By accepting these terms & conditions I/we authorise Lloyd's, their underwriting agents and Platinum Auto Insurance Limited to; 
         1. check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access; 
          2. disclose personal information to other interested members of the insurance industry and/or parties who have a financial interest in the subject matter of this insurance; 
          3. obtain personal information held by any other party regarding my/our existing and previous insurances;
  • I/we understand that there are rights of access to and correction of information held by Platinum Auto Insurance Limited, their underwriting agents and Lloyd's and the Insurance Claims Register.

Broker Appointment:
By accepting these terms and conditions I/we confirm that I/we have appointed The Insurance Group Limited and PAI as Insurance and Risk advisers (hereinafter referred to as "PAI").      

This authority cancels all previous authorities.  I/we understand that on authorisation from me/us, insurance will be placed with insurance companies by The Insurance Group Limited.

Disclosure

We are a privately owned insurance advisory firm.

Remuneration

PAI will be remunerated by commission from the insurer when I/we enter into an insurance contract that PAI arrange (this includes renewals and variations). The rates of commission may vary between insurers.  PAI may also charge me/us a fee.  Remuneration to PAI can include investment income from handling premium funds due to payment arrangements as provided for in the Insurance Intermediaries Act 1994.  If PAI arrange premium funding for me/us, PAI may earn a commission from the premium funder. The policy charge shown is the total premium payable and includes insurance costs, any fees charged, government levies and GST.

Authority to Renew

If a policy is renewable, PAI will automatically renew it on the due date unless advised in writing not to renew the policy.

Privacy Statement

PAI are committed to protecting my/our privacy.  PAI use the information I/we provide to advise about and assist with my/our insurance needs.  PAI only provide my/our information to the companies whom PAI recommend or whom I/we choose to deal with (and their representatives).  PAI do not trade, rent or sell your information.
If I/we do not provide PAI with full information, PAI cannot properly advise me/us and I/we could breach PAI's duty of disclosure.  I/we can check the information PAI hold about me/us at any time.

Cancellation

I/We agree that in the event of non-payment of premiums that The Insurance Group Limited shall have the authority to cancel any such affected policy following not less than 7 days notice in writing to me/us and my/our last known address. This clause applies equally whether the debt is owed to The Insurance Group Limited, or on any premium funding organisation or company.  PAI will cancel a policy arranged on my/our behalf, when instructed by me/us to do so.
Where any insurance on which PAI have been paid commission, is cancelled, PAI will retain the commission and fees if any.  PAI will pay to me/us any premium refunded by the insurer.

Insurance Rating

I/We understand PAI will use all reasonable precautions in choosing an insurance company(ies) and will advise me/us of their claims paying rating as per the Insurance Companies (Rating and Inspections) Act 1994.
I/We understand PAI cannot guarantee the financial status of any company and do not accept any liability due to the failure of any insurance company.

Duty of disclosure

We have a duty to disclose certain information  to the Insurer, This duty of disclosure applies before I/we enter into a contract of insurance for the first time, when I/we renew, when I/we vary or extend that contract and at any time my/our circumstance/s change during the period of insurance.
When I/we enter into a particular contract of insurance with the Insurer for the first time, I/we will be asked to answer specific questions on the insurance proposal form.  I/We must answer those truthfully and accurately to comply with my/our duty of disclosure.
On renewal, I/we are expected to disclose to my/our insurer every matter that I/we know, or could reasonably be expected to know, that may be relevant to the Insurer's decision whether to accept the risk and on what terms.

I/We do not have to disclose anything that;

  • Diminishes the risk to be undertaken by the Insurer;
  • Is common knowledge;
  • My/Our Insurer knows, or in the ordinary course of its business, ought to know; or
  • My/Our Insurer has waived from my/our obligation to disclose.

If I/we do not comply with my/our duty of disclosure, the Insurer may be entitled to reduce their liability in respect of a claim or they may be entitled to cancel my/our contract of insurance. If the non-disclosure was fraudulent, the Insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that I/we were never insured.
One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As I/we are responsible for checking that I/we have made complete disclosure, PAI suggest that you keep an up to date record of all such losses and claims.
If I/we have any questions about whether information needs to be disclosed, or want additional help, please contact PAI.

Declaration

  • I/we declare that the information given in this form to be true, correct and complete.
  • I/we agree that, should there be any dispute over the payment of any claim, PAI, their underwriting agents and Lloyd's shall be entitled to submit the dispute to arbitration, and that no information has been withheld that should have been disclosed.
  • In the event of a claim, I/we authorise and request the New Zealand Police to release to Lloyd's, their underwriting agent and PAI copies of all or any documents held by the New Zealand Police relating to any incident giving rise to a claim.  If necessary this authority should be treated as a formal request pursuant to the Official Information Act, 1982.
  • I/we authorise the disclosure of personal information held by any other party regarding any claim.
  • I/we agree to Lloyd's, their underwriting agents and PAI releasing to other appropriate parties personal information regarding any claim.

I/we authorise the Insurer or its authorised agent to give or obtain from other insurers or other parties any information relating to any insurance and Lloyd's.


Note: Failure to provide full and correct information could result in any claim not being accepted by PAI, their underwriting agents and Lloyd's.

Terms and Conditions
I have read and accept the terms and conditions
*