Rideshare Insurance

Form Name

Form Version

Lead ID

CRM Layout ID

Lead Source

Lead Type

Existing or New Business

Business Type

Industry

Country

Application Sent

Application Received

IMPORTANT:

This quote covers ride sharing operations for reward. For cover to be valid, the vehicle must be registered as a “business vehicle" noting “Point to Point Passenger Pickup” (or similar) on the vehicle's CTP.

All drivers must be over 23 years of age and have a minimum of 2 years recent driving experience on a “C” class licence as a minimum requirement.

First Name *

Last Name *

Phone *

Mobile *

E-mail *

Date of Birth *

Day Month Year

Street Address *

State *

City *

Postcode *

Business Description *

Type of Ridesharing *

Hours Per Week *

Ridesharing Experience (Years) *

Ridesharing Experience (Months) *

Driving Experience (Years) *

Minimum 2 years required

Driving Experience (Months) *

Licence Number *

Class of Licence *

Minimum 'C' class licence required

Year *

Make *

Model *

VIN *

Registration Number *

Registered State *

Sum Insured (excluding GST) *

Excess Level *

Is your vehicle financed? *

Yes No

Who is your vehicle financed through? *

Removal of Windscreen Excess Required? (not available for all vehicles) *

Yes No

Have you had any claims/accidents/damage to the vehicles in the last 5 years? *

Yes No

Please provide full details of claims/accidents/damage *

Attach claims history on previous insurer's letterhead

Have you had any licence suspensions, cancellations or endorsements? *

Yes No

Please provide full details of licence suspensions/cancellations/endorsements *

Have you had any traffic or speeding offences in the last 3 years? *

Yes No

Please provide full details of traffic or speeding offences *

Have you ever had insurance refused/declined/cancelled or special terms imposed? *

Yes No

Please provide full details of insurance refusals/cancellations or special terms *

Have you ever been convicted of fraud, arson, theft or any other criminal act? *

Yes No

Please provide full details of convictions *

Have you ever been convicted of drug use or driving under the influence? *

Yes No

Please provide full details of drug/alcohol convictions *

Have you ever been declared bankrupt or filed for bankruptcy? *

Yes No

Please provide full bankruptcy details *

Current Insurer *

Proposed Start Date *

Day Month Year

Comprehensive Cover Required? *

Yes No

Third Party Property Damage Cover Required? *

Yes No

Insured Amount *

Agreed Value *

General Liability Cover Required? *

Personal Accident Cover Required? *

Yes No

Duty of Disclosure Notice

Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, may affect their decision to insure you and on what terms.

You have this duty until they agree to insure you.

You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell the insurer anything that:
   - reduces the risk they insure you for; or
   - is common knowledge; or
   - they know or should know as an insurer; or
   - they waive your duty to tell them about.

If you do not tell the insurer something
If you do not tell the insurer something you are required to, they may cancel your contract or reduce the amount they will pay you if you make a claim, or both.

If your failure to tell them is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed.

I have read, understand and agree to the above Duty of Disclosure notice*

Agree to Duty of Disclosure? *

Yes

I have read, understand and agree to the Financial Services Guide*
A copy of this can be found at http://www.amsinsurance.com.au/downloads/AMS_FSG.pdf

Agree to FSG? *

Yes

I have read, understand and agree to the Privacy Policy*
A copy of this can be found at http://www.pscconnect.com.au/privacy/

Agree to Privacy Policy? *

Yes

Signature *

Please verify that you are human *

1. Your Details

2. Vehicle Details

3. Claim History

4. Coverage Details

5. Acknowledgements