RURAL APPLICATION PAGE 1 NZI, a business division of IAG New Zealand Limited RURAL INSURANCE Application Form NZ705/10 02/10 NZI RURAL INSURANCE APPLICATION FORM DETAILS OF APPLICANT(S) APPLICANT 1 First name: Surname: Occupation: Date of birth: APPLICANT 2 First name: Surname: Occupation: Date of birth: POSTAL ADDRESS Number/Street: Suburb: Town/City: CONTACTS Telephone: Mobile: Email: Covers already with NZI None House Contents Car Boat Business Period of Insurance From To at 4pm Farm location (a) Farm location (b) Any non farm activities? YES NO If ‘Yes’, please supply details Farm supply number (for dairy) Type of farming: Dairy (108) Horticulture (120/126) Pig (113) Sheep (114) Lifestyle (115) Crop (392) Deer (109) Poultry (102) Beef (107) Horse (100) PAYMENT OPTIONS How do you wish to pay? Annually Quarterly* Monthly* *Please complete an NZI Direct Debit Authority form. YOUR DUTY OF DISCLOSURE You must tell us all information you know (or could reasonably be expected to know) which would influence the judgement of a prudent underwriter whether or not to accept your application, and if it is accepted, on what terms and at what cost. Examples of information you may need to disclose include: • anything that increases the risk of an insurance claim; • any criminal convictions in last 7 years or where imprisoned; • if another insurer has cancelled or refused to renew insurance, or has imposed special terms; • any insurance claim you have made in the past. Examples of information you do not need to disclose include: • anything that reduces the risk of an insurance claim; • anything we say you do not need to tell us about; • anything that is common knowledge; • anything you have already told us, or that we should be expected to know in the ordinary course of our business. These examples are a guide only. If you are not sure whether you need to disclose a particular piece of information, please ask. WHEN IN DOUBT – DISCLOSE. ALL INFORMATION WILL BE TREATED CONFIDENTIALLY. Agent’s Name: Policy Number New Client Existing Client
26
Embed
nZi RuRal insuRance application FoRM · RuRal application nZi, a business division of iaG ew Zealand limited Ru Ral insu ance application Form Z705/10 02/10 PAGE 1 nZi RuRal insuRance
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
RuRal application
PAGE 1nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
nZi RuRal insuRance application FoRM
DEtailS oF applicant(S)
applicant 1
First name: Surname:
occupation: Date of birth:
applicant 2
First name: Surname:
occupation: Date of birth:
pOstal aDDRess
number/Street:
Suburb: town/city:
cOntacts
telephone: Mobile: Email:
covers already with nZi none House contents car Boat Business
period of insurance From to at 4pm
Farm location (a)
Farm location (b)
any non farm activities? YES no
if ‘Yes’, please supply details
Farm supply number (for dairy)
type of farming: Dairy (108) Horticulture (120/126) pig (113) Sheep (114) lifestyle (115) crop (392)
Deer (109) poultry (102) Beef (107) Horse (100)
paYMEnt optionS
How do you wish to pay? annually Quarterly* Monthly* *Please complete an NZI Direct Debit Authority form.
YouR DutY oF DiScloSuRE
You must tell us all information you know (or could reasonably be expected to know) which would influence the judgement of a prudent underwriter whether or not to accept your application, and if it is accepted, on what terms and at what cost.
examples of information you may need to disclose include:
Rewards cover Rural Service utilities cover $10,000
Stolen Keys cover $10,000 unharmed property
RuRal application
PAGE 4 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal Business inteRRuptiOn
SuM inSuRED
code cover Material Damage natural Disaster
Sum insured Rate/premium Sum insured Rate/premium
inploss of insured profit (incl increase in cost of Working)
RRV loss of Rent
DWBDual Wages – 100% for the balance with the option to consolidate to
weeks,
plus %
weeks
Wln Wages in lieu of notice weeks
pDBDual payroll – 100% for the balance with the option to consolidate to
weeks,
plus %
weeks
pFB payroll
aeW additional increased cost of Working
cpc claims preparation costs
232 Book Debts
ROR Rewriting of Records
total
inDEMnitY pERioD
6 months 9 months 12 months other: Months
include Machinery Breakdown Extension? Yes no
note: a sum insured calculation sheet for Business interruption is available at the rear of this application
RuRal application
PAGE 5nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal MacHineRY BReakDOWn
unSpEciFiED MacHinERY
Electrical and mechanical plant that:• islessthan5kw(6.75hp)
• hasanindividualreplacementvalueoflessthan$2,500
number of Machines Sum insured $ Office use Only
Rate premium
SpEciFiED MacHinERY
code Year Description Sum insured Office use Only
Rate premium
202 $
202 $
202 $
202 $
aDDitional policY EXtEnSionS
code Extension Year Description Sum insured Office use Only
Rate premium
pMp Submersible pump $
pMp Submersible pump $
205 Expediting costs $
excess Standard $500 Voluntary $1,000
RuRal application
PAGE 6 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal stOck DeteRiORatiOn
code Description of Stock
(produce, bulbs, semen straws etc)
type of Storage chamber
cryogenic Extn Sum insured (current Value)
Office use Only
Rate co. premium
YES no $
YES no $
YES no $
YES no $
total Sum insured
Standard Excess : 10% Voluntary Excess : 20% 30% 50% Does the sum insured for stock represent full current value? YES no
note: it is a requirement of this insurance that all the refrigerated stock must be insured for its replacement value. in the event of under insurance, the insured will be required to be their own insurer for the difference.
is the refrigerating machinery:
(a) maintained by your own engineering staff? YES no
(b) the subject of a regular maintenance contract? YES no
(c) connected to a monitored automatic alarm system? YES no
note: the refrigeration machinery must be insured under a nZi Machinery Breakdown policy.
Do you store goods belonging to others? YES no
is there a reserve generator, or alternative storage facilities, available? YES no
the Meaning of ‘subject to average’1. Your insurance policy contains a provision making it ‘subject to average’.
2. that provision will have effect only if the property insured under the policy is underinsured at the time of loss.
3. if the property insured under the policy is underinsured at the time of loss the following rules apply:
(a) if you suffer a total loss, the provision will have no effect.
(b) if you suffer a partial loss, the maximum amount that you may recover will bear the same proportion to your actual loss as the amount for which the property is insured bears to the full value of the property.
(c) Whatever your loss, in no case will you be entitled to recover more than the amount for which the property is insured.
Example: Your property is worth $20,000. You insure it for $10,000. You suffer a loss of $5,000. If your policy is ‘subject to average’, the maximum amount that you may recover will be $2,500.
RuRal application
PAGE 7nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal liaBilitY
BRoaDFoRM liaBilitY
annual turnover annual Wages number of Employee’s number of Years on Farm
$ $
cover: Office use Only
$1,000,000 $2,000,000 other $ premium
excess $500is a voluntary excess required? Yes no
$1000 $2500 $5000
autoMatic EXtEnSionS
agricultural contracting - $250,000
Defective Design liability - $250,000
Exemplary Damages - $1,000,000
Food poisoning of animals - $250,000
Hunt club Meetings
loading and unloading liability
Motor Repair or Storage liability - $250,000
product Withdrawal costs (nZ only) - $100,000
underground Services liability
Welding, Gas cutting, Burning off liability
Bailees liability - $250,000
Errors & omissions liability
Farmstay liability
Forest & Rural Fires act - $250,000
landlords liability
Mechanical Mobile plant liability
pollution liability
Roadside Grazing
Removal of Support - $250,000
Office use Only
Do you require cover under the Forest & Rural Fires act in excess of the standard $250,000? Yes no
premium
$500,000 $1,000,000 $2,000,000
Have any circumstances in the last 5 years occurred that could result in a claim under this cover that you are applying for? Yes no
if ‘Yes’, please give details below and/or on a separate page:
Do you ever undertake any work away from your farm? Yes no
if ‘Yes’, please give details below and/or on a separate page:
Do you ever look after property not belonging to you? e.g. animals, produce, machinery? Yes no
if ‘Yes’, please give details below and/or on a separate page:
Do you undertake contracting work? Yes no
if ‘Yes’, what percentage of your annual turnover is obtained from contracting? %
RuRal application
PAGE 8 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
Does your contracting work ever involve non agricultural activities? Yes no
if ‘Yes’, please give details below and/or on a separate page:
StatutoRY liaBilitY
standard cover: $500,000is additional cover required? Yes no
Office use Only
$1,000,000 premium
excess: $500is a voluntary excess required? Yes no
$1000 $2500 $5000
Have any circumstances in the last 5 years occurred that could result in a claim under this cover that you are applying for? Yes no
if ‘Yes’, please give details below and/or on a separate page:
Resource Management actDo you need, or have you ever applied for a resource consent and/or a certificate of compliance under the Resource Management act? Yes no
if ‘Yes’, please give details below and/or on a separate page:
animal products act & animal Welfare actHave you ever been involved in any investigation or proceedings under, or had compliance notices served upon you, or had fines imposed upon you for any breach of either the animal products act or the animal Welfare act? Yes no
if ‘Yes’, please give details below and/or on a separate page:
EMploYERS liaBilitY
standard cover: $500,000is additional cover required? Yes no
Office use Only
$1,000,000 premium
excess: $500is a voluntary excess required? Yes no
$1000 $2500 $5000
number of Employees: Full time: part time: Seasonal:
Have any circumstances in the last 5 years occurred that could result in a claim under this cover that you are applying for? Yes no
if ‘Yes’, please give details below and/or on a separate page:
accare you an ‘exempt’ or ‘accredited’ employer under current acc legislation? Exempt accredited
annual acc levy: $
RuRal application
PAGE 9nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal cOMMeRcial MOtORgross Vehicle Weight or cc Rating: For cars, utes, vans and light trucks up to 3,500kgs, please provide the engine cc rating (e.g. 2000cc). For trucks, trailers, mobile plant over 3,500kgs, please provide the gross laden weight (GlW).Gross laden weight means the vehicle weight plus load capacity.cover type: please indicate which cover is to apply in the cover column below:c = comprehensive. F = third party, Fire theft & illegal conversion.t = third party only.
item no.
Year of Manufacture
Make, Model & type of Vehicle
Rego. no. Gross laden Weight or cc Rating
Market Value
cover type
ncB Office use Only
Rate prem govt levy
1 $
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
OptiOnal eXtensiOns
tick where required. please refer to policy wording for full definitions of extension. if an increase to the standard policy limits is required, please provide details.
item 1 2 3 4 5 6 7 8 9 10
303 Foreign objects
312 contracting
SMp agreed Value – Specialist Mobile plant only (Valuation Required)
aMp appreciation – Mobile plant only
RFc liability for Rental Vehicles (Full cover)
RRE liability for Rental Vehicles (Restricted cover)
excess: $400is a voluntary excess required? Yes no
i authorise you to give nZi any medical information you have regarding me.
Signature: Date:
Medical authority: person 2
Doctor:
address:
i authorise you to give nZi any medical information you have regarding me.
Signature: Date:
RuRal application
PAGE 12 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
Medical History: person 1
Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory, orrespiratorysystems;cancer;arthritisorrheumatism;backorspinecomplaints;hernia;diabetes; abnormalbloodpressure;orheartdisease? Yes no
Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned? Yes no
are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent medical condition or complaint, or have you any physical defect, disability or impairment? Yes no
Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind? Yes no
Have you ever used or injected yourself with any drug not prescribed by a doctor? Yes no
Have you ever been on a programme of drugs, pills or other medication? Yes no
Have you ever had any disorder relating to menstruation or pregnancy? Yes no
are you pregnant? Yes no
if ‘Yes’, expected date of delivery:
if you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:
Medical History: person 2
Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory, orrespiratorysystems;cancer;arthritisorrheumatism;backorspinecomplaints;hernia;diabetes; abnormalbloodpressure;orheartdisease? Yes no
Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned? Yes no
are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent medical condition or complaint, or have you any physical defect, disability or impairment? Yes no
Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind? Yes no
Have you ever used or injected yourself with any drug not prescribed by a doctor? Yes no
Have you ever been on a programme of drugs, pills or other medication? Yes no
Have you ever had any disorder relating to menstruation or pregnancy? Yes no
are you pregnant? Yes no
if ‘Yes’, expected date of delivery:
if you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:
RuRal application
PAGE 13nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
RuRal liVestOck
WoRKinG DoGS
unspecified Working Dogs
number of dogs: @ $750 per dog = Sum insured $
Office use Only
Rate co. premium
specified Dogs
name Gender age*illness & Disease Extn
Sum insured
M/F Yes no $
M/F Yes no $
M/F Yes no $
M/F Yes no $
*note: the policy applies an age limit on the dogs covered of 4 months to 9 years.
WoRKinG HoRSES
code Description of Horse Gender age* Sum insured Office use Only
Rate co. premium
M/F $
M/F $
M/F $
M/F $
M/F $
total Sum insured $
*note: the policy applies an age limit on the horse covered of 12 months to 14 years
are the horses in good health and free from injury, disability, physical abnormality or illness? Yes no
Have any of the horses suffered from any unsoundness or illness in the last 12 months? Yes no
if ‘Yes’, please give details:
note: a veterinary certificate of health must be obtained for any horse valued over $5,000.
RuRal application
PAGE 14 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
liVEStocK
cover Selected: individual animal Herd cover* transit only cover 30 day cover
code Description Species Gender age Sum insured Office use Only
Rate co. premium
M/F $
M/F $
M/F $
M/F $
total Sum insured $
* please attach a schedule of the animals to be insured.
additional cover
code Extension Office use Only
Rate co. premium
707 tuberculosis Yes no
702 Dehorning & Velveting Yes no
709 theft & Escape Yes no
713 unborn offspring Yes no
are the animals in good health and free from injury, disability, physical abnormality or illness? Yes no
Have any of the animals suffered from any unsoundness or illness in the last 12 months? Yes no
if ‘Yes’, please give details:
Were the animals brought at auction during the last 12 months? Yes no
note: a veterinary certificate of health may be required for any animal not bought at auction during the last 12 months.
RuRal application
PAGE 15nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
What is this address? Your usual residence Holiday/Weekend Home Vacant/unoccupied
Who owns the home? You Relative/Employer landlord other(Specify)
if you are not the owner are you:
(a) Sharing with the owner? (b) the only tenant?
(c) Sharing with your spouse and/or family? (d) Sharing with others (not spouse or family)?
if sharing with others (d) how many people live at home in total (including you)?
WHO Will Be cOVeReD? insurance will cover contents owned by the person making this application, and their legally married spouse and any children who live at the address above.
Is Insurance required for Contents owned (or jointly-owned) by anyone else? (eg de facto partner, grandparents etc). if ‘Yes’, you must give their details below or their contents will not be covered. Yes no
SEcuRitY
is the house fitted with a burglar alarm? Yes no
Does it include an external siren? Yes no
Y n
023$Y n Y n
002$MultioFFicE uSE onlY
Y n Y n
n200nMiB
aBRV.St
oFFicE uSE onlY
RuRal application
PAGE 17nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
Was it fitted professionally? Yes no
is it professionally monitored? Yes no
Do all external doors have deadlocks? Yes no
Do all accessible external windows have keyed window locks? Yes no
policY liMitS
itEMS nZi ESSEncE nZi EcHElon HouSEHolDERS
1. Watch or item of jewelleryany item $3,000 $3,000 $1,500
total all items $10,000 $15,000 (jewellery) $10,000
4. Stamps, medals, phonecards, coins, trading cards total each category $750 $1,000 $1,000
5. Money, bullion, precious metals, cut or uncut stones total each category $750 $1,000 $250
6. Home office furniture and equipment (while at the home) total all items not covered $10,000 $1,000
Do you wish to apply for cover above any of these limits? Yes no if ‘Yes’, please give details below:
DEScRiption oF itEM Valuation nuMBER ValuE $
$
$
$
notE: the policies do contain other limits - please refer to the policy wording for full details.
age DiscOunts: please indicate your age group - you may qualify for a discount
up to 49 years 50-59 years 60 years and over
policY EXcESS
Standard Excess $250 plus additional Voluntary Excess (with premium Discount) $150 $400 $750
SuM inSuRED
total insurable value of all contents $
MOtORplease tick which type of vehicle you are insuring car Motor cycle caravan trailer other (Specify)
please tick which type of cover required Standard third party Fire & theft third party only
Make and Model of vehicle: Date of Manufacture:
Registration number: Market Value of Vehicle ($) Engine Size: (cc)
Y n
nalX oFFicE uSE onlY
Y n
nalMoFFicE uSE onlY
Y n
nSRX oFFicE uSE onlY
RuRal application
PAGE 18 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
Fuel type: petrol Diesel transmission: automatic Manual turbo: Yes no Rotary: Yes no
Has the original engine been replaced or modified? Yes no if ‘Yes’, give full details
Have the original wheels been replaced? (other than replacement of tyres) Yes no if ‘Yes’, give full details
Has the bodywork or suspension been modified? Yes no if ‘Yes’, give full details
Has the vehicle been fitted with a stereo system worth more than $1,000? Yes no if ’Yes’, give full details
please tick any of the following which apply to your vehicle Sports or performance convertible/cabriolet Kitset/Replica
left-hand Drive classic/Vintage orphan Hybrid
Does the vehicle have a car alarm or immobiliser? Yes no if ‘Yes’, complete (a), (b) and (c) below
(a) alarm immobiliser
(b) Was the alarm or immobiliser fitted by the manufacturer before the vehicle was sold new in new Zealand? Yes no
(c) advise nZSa Star Rating 1 2 3 4 5
if not rated, give details of system
Where is the vehicle usually parked at night? Garage Driveway/carport on Roadside other (Specify)
Will the vehicle be used in connection with any profession, business or occupation? Yes no if ‘Yes’, give full details
DEtailS oF tHE oWnER(S) & DRiVER(S)
Full naME DatE oF BiRtH SEX (M/F) occupation pHonE
nuMBERDRiVER tYpE (SEE BEloW)
licEncE tYpE (SEE BEloW)
lEnGtH oF licEncE HElD
1. Yrs Mths
2. Yrs Mths
3. Yrs Mths
4. Yrs Mths
5. Yrs Mths
Driver type – Select from: M (Main), R (Regular), n (non driver) licence type – Select from 1 (learner), 2 (Restricted), 3 (Full), 4 (international)
RatEaREaY n
loW KMY n
u25Y n
BRKY n
HFEM F
SEXoFFicE uSE onlY
/ /
DoBY n
naMEDRiVERGRaDinG
RuRal application
PAGE 19nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
DEclaRation QuEStionS
Have you or anyone else who will drive this vehicle had any motor vehicle accidents, damage or theft in the last 5 years (whether a claim was made or not)? Yes no
Have you or anyone else who will drive this vehicle ever indefinitely been disqualified from driving for repeat alcohol or drug related driving offences? Yes no
aDDitional inFoRMation
Do you want to apply for nZi Roadside assist cover? (Standard cover only) Yes no
Do you want a named Drivers Discount? (up to 2 of the drivers listed on page 18 can be named – both must be aged 25 yrs or older) Yes no
if ‘Yes’, please tick the two drivers chosen. 1 2 3 4 5
if self-built – Materials price paid: Estimate labour costs:
Engine Make: number of Engines: Hp:
Engine type: petrol Diesel outboard inboard Stern leg Shaft Drive
other – state type: Year manufactured: Serial no(s):
pREciSE location oF inSuRED cRaFt WHEn not in uSE
lOcatiOn 1
Mooring type/storage location: Mooring number:
lOcatiOn 2
Mooring type/storage location: Mooring number:
RuRal application
PAGE 20 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
SEcuRitY
FiRe eXtinguisHeR(s)
type: number of:
Describe type of trailer anti-theft locking device:
Describe security alarm system:
liSt oF pRopERtY to BE inSuRED
aMOunt insuReD
Hull, fixtures, fittings and machinery (includes outboard motors) $
Mast, spars, rigging and sails (sailboats only) $
Boat trailer make Reg no $
crafts gear (*see definition) plus dinghies, auxilliary outboards etc. $
*crafts gear means the items used with the craft, such as electronic equipment including radio telephones, depth sounders, GpS, chart plotters, marine software, radar, sonar, audio and tV systems, navigation equipment, tenders, outboard motors, warps, ropes, ground tackle, safety equipment, galley appliances and other items which would normally be sold with the craft.
tHe FOllOWing iteMs aRe eQuipMent tO Be insuReD nOt nORMallY puRcHaseD OR sOlD WitH tHe insuReD cRaFt
Will the boat be used for other than private purposes (skippered charter, bare boat charter etc)? YES no
if ‘Yes’, give details
RacinG notE: RacinG coVER iS aVailaBlE SolElY on YacHtS anD tRailER-SailERS
the policy conditions exclude cover for loss to sails, masts, spars or rigging while racing unless optional additional racing cover is taken.
Will the boat be used for racing? YES no
if ‘Yes’, do you require the Racing Risk extension? (optional additional benefit)
RuRal application
PAGE 21nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
uSER EXpERiEncE
Who is the main user of the craft?
Give details of their boating experience
Give details of any accident with any craft the main user has had in the past three years, whether insured or not
Do they have a Boatmasters certificate or similar? YES no
if ‘Yes’, give details
note: to qualify for discount, the Boatmasters or other relevant certificate must be produced.
plEaSE coMplEtE tHE FolloWinG SaFEtY REpoRt
plEaSE anSWER EacH QuEStion BY ticKinG EitHER YES oR no. WHERE a WRittEn anSWER iS REQuiRED plEaSE uSE BlocK lEttERS.
1. are bilge pumps fitted? YES no
2. is a float switch fitted? YES no
3. a) are all underwater through hull fittings equipped with gate valves/sea cocks? YES no
b) are all sea cocks and valves operational? YES no
4. IsthegasstoveinstalledinaccordancewithN.Z.S5428;ieisbottleondeckorincockpitlockervented overboard and are lines of approved material? YES no
5. are fuel tanks externally vented? YES no
6. if petrol engine, is a bilge blower and gas detector installed and operational? YES no
7. are spare anchors carried on board? YES no
8. is there an alternative means of propulsion (oars, paddles, auxiliary motor)? YES no
9. Do you carry a set of flares? YES no
10. Do you hold charts for all the areas in which you operate? YES no
11. is there another fire extinguishing system? YES no
12. is the engine fitted with an audible pressure/temperature alarm system? YES no
13. can you sail a yacht? YES no
14. Have you studied navigation? YES no
15. Have you attended any courses on diesel engines? YES no
16. if on a swing mooring, is it designed for this vessel? YES no
17. is the mooring subject to a current lease issued by a controlling authority? YES no
18. is the mooring lifted from the water and inspected in accordance with regulations or at least once every two years where none apply? YES no
19. are all mooring deficiencies remedied promptly? YES no
nOtes
RuRal application
PAGE 22 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
inSuRancE HiStoRY
please answer each question on behalf of all customers listed above.1. Has any insurance company:
(a) refused to insure any customer, or refused to continue to insure any customer, or
imposed special terms? Yes no
(b) refused any customer’s claim in respect of any insurance? Yes no
2. (a) Has any customer, during the last five years, made a claim in respect of the types of insurance being sought? Yes no
(b) is any customer aware of any circumstances that may result in a claim under any of the types of insurance being sought? Yes no
3. Has any customer (or any director or manager of any customer) been sued for unpaid debts, or managed a company placed in receivership or liquidation? Yes no if you answered ‘Yes’ to any part of questions 1 to 3 above, please give details below and/or on a separate page.
4. Have you or anyone who will drive any vehicle you are insuring:(a) ever been imprisoned for any criminal or driving offence, or
(b) had any conviction or fine for either a criminal or driving offence within the last 7 years, or
(c) any prosecution pending for any criminal or driving offence?
if ‘Yes’, please give full details:
DatE oF conViction natuRE oF oFFEncE aMount oF MonEY inVolVED SEntEncE iMpoSED
5. Does anyone (other than the insured) have a financial interest in any property, machinery or motor vehicles? Yes no
if ‘Yes’, please give details of interested party:
inSuRED itEM DEtailS intEREStED paRtY naME intEREStED paRtY aDDRESS
property
Machinery
RuRal application
PAGE 23nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10
Motor Vehicles
plEaSE notE: this information is safeguarded by the privacy act 1993.
inSuRancE coVER taKEn/ not taKEn (cHEcKliSt)
pROpeRtY insuRance Rural Material Damage taken/not takenRural Business interruption taken/not taken
liaBilitY insuRance Rural General (Broadform) liability taken/not takenRural Statutory liability taken/not takenRural Employers liability taken/not taken
cOMMeRcial MOtOR insuRance taken/not taken
OtHeR insuRance income protection taken/not takenMachinery Breakdown taken/not takenStock Deterioration taken/not takenlivestock taken/not taken
peRsOnal insuRanceHouse taken/not takencontents taken/not takenMotor Vehicle taken/not takenBoat taken/not taken
aGREEMEnt
i agree that:
1. MateRial Facts (a) AllinformationgiventoNZI(whetherverbalorwritten)istrueandcorrect;
2. teRMs OF pOlicY ThetermsofNZI’spolicyareaccepted;
3. use OF inFORMatiOn (a) My personal information collected by nZi may be:
(i) usedbyNZItoadvisemeofitsotherservices;
(ii) disclosed to other members of the insurance industry and insurance claims Register ltd., and topartieswhohaveafinancialinterestinthesubjectmatterofthepolicy;
(b) My personal information held by other members of the insurance industry and insurance claims Register ltd., may be disclosed to nZi.
4. agencY anyone who assists me to complete this application Form is acting as my agent only.
On BeHalF OF all applicants Signature Date:
name:
position (Director, Secretary etc.): Date:
pRiVacY act StatEMEnt
We gather information about you (including your claims history) to consider your application for insurance. Your duty of disclosure requires you to do this. if you refuse to provide the information, we may decline your application or declare this policy unenforceable from the beginning.this information is held by us and you may access and seek correction of it. it may be passed on to other insurers you deal with, and interested parties.Your claims history is passed on to, and held by, insurance claims Register ltd. this enables other insurers you deal with to access it, and prevents fraudulent claims.
RuRal application
PAGE 24 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10