• RIDESHARE PROPOSAL FORM / QUICK QUOTE FORM

    RIDESHARE PROPOSAL FORM / QUICK QUOTE FORM

  • Driveline Hire Vehicle, Limousine or Ride Share Package Insurance (1 - 4 vehicles)

    • IMPORTANT INFORMATION - PLEASE READ BEFORE COMPLETING THIS FORM 

    • IMPORTANT INFORMATION - PLEASE READ BEFORE COMPLETING THIS FORM

    • Your Duty of Disclosure

    • Before You enter into a contract of insurance with Us, You have a Duty,under the Insurance Contracts Act 1984, to disclose to Us every matter that You know, or could reasonably be expected to know, is relevant toOur 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 Us before You renew, extend, vary or reinstate the contract.

      This Duty of Disclosure applies until the contract is entered into (or renewed, extended, varied or reinstated as applicable).Your Duty however does not require disclosure of any matter:

      • that diminishes the risk to be undertaken by Us; or
      • that is of common knowledge; or
      • that We know or, in the ordinary course of Our business as an insurer, ought to know; or
      • as to which compliance with Your Duty is waived by Us

    • Non-disclosure:

      If You fail to comply with Your Duty of Disclosure, We may be entitledto reduce Our liability under the contract in respect of a claim, cancel the contract, or both. If Your non-disclosure is fraudulent, We may also have the option ofavoiding the contract from its beginning.

    • PRIVACY NOTICE

    • We give priority to protecting the privacy of Your personal information. We do this by handling personal information in a responsible manner and in accordance with the Privacy Act 1988 (Cth). In this Privacy Notice, ‘We’, ‘Our’, ‘Us’ means Connect Business Insurance Pty Ltd. 

      How We collect Your personal information

      We usually collect Your personal information from You or Your agents. We may also collect it from Our agents and service providers; other insurers and insurance reference bureaus; people who are involved in a claim or assist Us in investigating or processing claims, including third parties claiming under Your Policy, witnesses and medical practitioners; third parties who may be arranging insurance cover for a group that You are a part of; law enforcement, dispute resolution, statutory and regulatory bodies; marketing lists and industry databases; and publicly available sources.

      Your personal information may be disclosed to other companies in the Allianz Group, business partners, reinsurers and service providers that may be located in Australia or overseas. The countries to which this information may be disclosed will vary from time to time, but may include Canada, Germany, New Zealand, United Kingdom, United States of America and other countries in which Connect Business Insurance has a presence or engages subcontractors. We regularly review the security of Our systems used for sending personal information overseas. Any information disclosed may only be used for the purposes of collection detailed above and system administration.

    • Why We collect Your personal information

      We collect Your personal information to enable Us to provide Our products and services, including to process and settle claims; make offers of Our products and services provided by Us, Our related companies, brokers, intermediaries and business partners and others that We have an association with that may interest You; and conduct market or customer research to determine those products or services that may suit You. You can choose not to receive product or service offerings from Us (including product or service offerings from Us on behalf of Our brokers,intermediaries and/or Our business partners) or Our related companies by calling: Connect Business Insurance on 1300 477 662. If You do not provide Your personal information We require, We may not be able to provide You with Our services, including settlement of claims

    • Who We disclose Your personal information to

      We may disclose Your personal information to others with whom We have business arrangements for the purposes listed in the paragraph above or to enable them to offer their products and services to You. These parties may include insurers, intermediaries, reinsurers, insurance reference bureaus, related companies, Our advisers, persons involved in claims, external claims data collectors and verifiers, parties that We have an insurance scheme in place with under which You purchased Your Policy (such as a financier or motor vehicle manufacturer and/or dealer). Disclosure may also be made to Government, law enforcement, disputeresolution, statutory or regulatory bodies, and industry databases or as required by law.

    • Disclosure overseas

      Your personal information may be disclosed to other companies in Connect Business Insurance, business partners, reinsurers and service providers that may be located in Australia or overseas. The countries to which this information may be disclosed will vary from time to time, but may include Canada, Germany, New Zealand, United Kingdom, United States of America and other countries in which the Allianz Group has a presence or engages subcontractors. We regularly review the security of Our systems used for sending personal information overseas. Any information disclosed may only be used for the purposes of collection detailed above and system administration.

    • Access to Your personal information and complaints

      You may ask for access to the personal information We hold about You and seek correction by calling:

      Connect Business Insurance on 1300 477 662 (8:30AM - 5PM Monday to Friday)

      Connect Business Pty Ltd T/as Connect Business Insurance is a Corporate Authorised Representative No 1241963. ABN 59 612 031 964 of Community Broker Network Pty Ltd ACN 096 916 184 AFSL 233750.

    • Our Privacy Policy contains details about how You may make a complaint about a breach of the privacy principles contained in the Privacy Act 1988 (Cth) and how We deal with complaints. Our Privacy Policy is available at cbn.au.

    • Telephone Call Recording

      We may record incoming and/or outgoing telephone callsfor training or verification purposes. Where We have recorded a telephone call, We can provide You with a copy at Your request, where it is reasonable to do so.

    • Your Consent

      By providing Us with personal information You and any other person You provide personal information for, consent to these uses and disclosures until You tell Us otherwise. If You wish to withdraw Your consent, including for such things as receiving information on products and offers by Us or persons We have an association with, please contact Us.

    • SUBROGATION

    • You may prejudice Your rights in relation to a claim made under this policy if without prior agreement from Us, You make an agreement with a third party that will prevent Us from recovering a loss from that or another party.

      We may record incoming and/or outgoing telephone calls for training or verification purposes. Where We have recorded a telephone call, We can provide You with a copy at Your request, where it is reasonable to do so.

    • DUTY OF UTMOST GOOD FAITH

    • Your Consent

    • By providing Us with personal information You and any other person You provide personal information for, consent to these uses and disclosures until You tell Us otherwise. If You wish to withdraw Your consent, including for such things as receiving information on products and offers by Us or persons We have an association with, please contact Us.

      Duty of Utmost Good Faith:

      Every insurance contract is subject to the duty of utmost good faith which requires both the Insured and the Insurer to act towards each other in utmost good faith. Failure to do so on the part of the Insured may prejudice any claim made under the policy or the continuation of insurance cover by the Insurer.

      Subrogation:

      You may prejudice Your rights in relation to a claim made under this policy if without prior agreement from Us, You make an agreement with a third party that will prevent Us from recovering a loss from that or another party.

    • CHANGE OF RISK OR CIRCUMSTANCE

    • It is vital that You provide Us with notification of any changes in Your risk profile which may be relevant to the terms and conditions of this insurance. This is including but not limited to changes in business activities and acquisitions which occur after the date of the Declaration.

    • GENERAL INSURANCE CODE OF PRACTICE

    • It is vital that You provide Us with notification of any changes in Your risk profile which may be relevant to the terms and conditions of this insurance. This is including but not limited to changes in business activities and acquisitions which occur after the date of the Declaration.

      The General Insurance Code of Practice was developed by the Insurance Council of Australia to further raise standards of practice and service across the insurance industry. The Code Governance Committee (CGC) is an independent body that monitors and enforces insurers’ compliance with the Code. You can obtain more information on the Code of Practice and how it assists you by contacting Us. Contact details are provided below and on the back cover of the Product Disclosure Statement or Policy Document.

    • THE INSURER

    • Connect Business Pty Ltd T/as Connect Business Insurance is a Corporate Authorised Representative No 1241963. ABN 59 612 031 964 of Community Broker Network Pty Ltd ACN 096 916 184 AFSL 233750.

    • COMPLETING THIS FORM/QUESTIONNAIRE:

    • Please complete all sections in full and provide any requested attachments.
      This form may be printed and completed in handwriting or it may be completed electronically as an interactive pdf with fillable form fields.

      If completing electronically, please download to your local computer and complete using Adobe Acrobat Reader (Fill & Sign tool If more space is required when completing this form, please attach a separate sheet.

      The use of the term 'You' or 'Your' in this form refers to an Insured and their subsidiary companies and other entities in which they have a controlling interest.

      The use of the term 'We', 'Our' or 'Us' in this form refers to the Insurer and its Underwriting Agency.

      It is important to refer to the relevant Product Disclosure Statement and Policy Document which sets out the terms and conditions of cover offered.

      Please contact Connect Business Insurance office or speak to your Intermediary.

  • Section 1: Insurance Broker Contact Details

  • Section 2: Client Business Details

  • Section 3: Your Insurance Details

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  • Section 4: Loss History

  • Please provide written details of any claims or uninsured losses in the last 5 years (Written confirmation from Insurers is required) (Note: If insufficient space please attach details)

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  • Section 5: Vehicle Information

  • Insured Vehicle 1:

    • Fill This Out For Multiple Vehicles: 

    • Insured Vehicle 2:

    • Insured Vehicle 3:

    • Insured Vehicle 4:

  • Section 6: Driver Details

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  • Section 7: Insurance History

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  • Section 8: Cover Requirements

  • This declaration applies to all the insurance You are applying for in this Proposal.

    • I/We hereby declare that:
    • upon acceptance, the terms and conditions of this insurance will be in accordance with the Product Disclosure Statement and Policy Document;
    • I/We have been truthful and accurate in completing this form and declaration and have not withheld any information likely to affect the terms of the acceptance of this insurance by the Insurer;
    • I/We have either completed this form personally or, if it has been on my/our behalf, have checked that the questions have been fully and accurately answered;
    • Where there is more than one Insured(s)/Policyholder(s) included on this form, I/We acknowledge that I/We are authorised to sign for and on behalf of the other Insured(s)/Policyholder(s);
    • I/We have read and understood the information concerning the Duty of Disclosure and other Important Notices on this form;
    • I/We have read and understood the Privacy Notice on this form and consent to the collection, storage, use and disclosure of any personal and sensitive information;
    • if I/We have not complied with the Duty of Disclosure and Duty of Utmost Good Faith, a claim made under the Policy may not be met or only met in part;
    • following acceptance, an occurrence during the Period of Insurance which alters any of the information I/We have provided on this form, will be promptly notified.
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