Black & White Insurance Solutions Quote Request Form

Black & White Insurance Solutions

Quote Request Form

For information on how we collect, store and use your information, please refer to our Privacy & Data Protection policy.

Black & White Holdings Pty Ltd act as a distributor of Taxi Insurance (Distributor) for Howden Insurance Brokers (Australia) Pty Ltd ABN 79 644 885 389, AFSL 539613 (“Howden”). Howden is licensed and authorised to deal in and provide financial advice in relation to all general and life insurance products.

As a Distributor of Howden, Black & White Holdings Pty Ltd are authorised to deal in the Taxi Insurance products arranged by it.

Black & White Holdings Pty Ltd can assist you in arranging Taxi Insurance, however are unable to provide you with any advice, recommendation or their own opinion in relation to these insurance products.

Black & White Holdings Pty Ltd receive remuneration paid by Howden for your access to the Taxi Insurance benefits.

A copy of the Howden’s Financial Service Guide and insurer Product Disclosure Statement/s will be made available to you.

Please consider these documents before deciding whether the relevant Taxi Insurance is right for you.

Your Business Details

Insured Name*

If it is a company name you are insuring please provide Operators name

Mobile Number*

Phone

Email*

Street Address*

Suburb*

State*

Select

Postcode*

Number of years you have owned a Taxi*

Number of vehicles you operate in total*

Financier Name (If applicable)

Your Insurance Details

Are these vehicles currently insured?*

Yes, this vehicle is currently insured

No, this vehicle is not insured. This is a new business venture

Who are you currently insured with

Select or enter value

If insured with another company, please advise:*

What is the cost of your current policy?

Approximate cost if actual cost is unknown

Insurance start date*

What date do you require this policy to start on

Vehicle Information

If you have more than 5 vehicles, please upload the list of vehicles.

1. Year*

1. Make & Model*

1. Registration / Plate No.*

1. VIN *

1. Odometer Reading (kms)*

1. Select all included Accessories

Dispatch System Equipment $1,400

Taximeter $500

Cabcharge EFTPOS Equipment $1,400

TaxicamHD Security Camera System $2,500

TaxicamHD Security Camera System MAXI $2,800

Personal EFTPOS Equipment $550

Other, please specify

1. Other Accessories including $ Value

1. Vehicle Cover*

Comprehensive

Third Party Only

1. Do you require finance payout cover?*

(additional premium applies):

Yes - 10% of the Sum Insured up to $10,000 limit

Yes - 20% of the Sum Insured up to $20,000 limit

Not Required

Do you have another vehicle to add?*

Yes

2. Year*

2. Make & Model*

2. Registration / Plate No. *

2. VIN*

2. Odometer Reading (kms)*

2. Select all included Accessories

Dispatch System Equipment $1,400

Taximeter $500

Cabcharge EFTPOS Equipment $1,400

TaxicamHD Security Camera System $2,500

TaxicamHD Security Camera System MAXI $2,800

Personal EFTPOS Equipment $550

Other, please specify

2. Other Accessories including $ Value

2. Vehicle Cover*

Comprehensive

Third Party Only

2. Do you require Total Loss of Encumbered Taxi Cover (finance payout)?*

(additional premium applies):

Yes - 10% of the Sum Insured up to $10,000 limit

Yes - 20% of the Sum Insured up to $20,000 limit

Not Required

Do you have more than 2 vehicles to add?*

Yes

3. Year*

3. Make & Model*

3. Registration / Plate No. *

3. VIN*

3. Odometer Reading (kms)*

3. Select all included Accessories

Dispatch System Equipment $1,400

Taximeter $500

Cabcharge EFTPOS Equipment $1,400

TaxicamHD Security Camera System $2,500

TaxicamHD Security Camera System MAXI $2,800

Personal EFTPOS Equipment $550

Other, please specify

3. Other Accessories including $ Value

3. Vehicle Cover *

Comprehensive

Third Party Only

3. Do you require Total Loss of Encumbered Taxi Cover (finance payout)?*

(additional premium applies):

Yes - 10% of the Sum Insured up to $10,000 limit

Yes - 20% of the Sum Insured up to $20,000 limit

Not Required

4. Year*

4. Make & Model*

4. Registration / Plate No.*

4. VIN*

4. Odometer Reading (kms)*

4. Select all included Accessories

Dispatch System Equipment $1,400

Taximeter $500

Cabcharge EFTPOS Equipment $1,400

TaxicamHD Security Camera System $2,500

TaxicamHD Security Camera System MAXI $2,800

Personal EFTPOS Equipment $550

Other, please specify

4. Other Accessories including $ Value

4. Vehicle Cover*

Comprehensive

Third Party Only

4. Do you require Total Loss of Encumbered Taxi Cover (finance payout)?*

(additional premium applies):

Yes - 10% of the Sum Insured up to $10,000 limit

Yes - 20% of the Sum Insured up to $20,000 limit

Not Required

5. Year*

5. Make & Model*

5. Registration / Plate No.*

5. VIN*

5. Odometer Reading (kms)*

5. Select all included Accessories

Dispatch System Equipment $1,400

Taximeter $500

Cabcharge EFTPOS Equipment $1,400

TaxicamHD Security Camera System $2,500

TaxicamHD Security Camera System MAXI $2,800

Personal EFTPOS Equipment $550

Other, please specify

5. Other Accessories including $ Value

5. Vehicle Cover*

Comprehensive

Third Party Only

5. Do you require Finance Payout cover?*

(additional premium applies):

Yes - 10% of the Sum Insured up to $10,000 limit

Yes - 20% of the Sum Insured up to $20,000 limit

Not Required

Cover Requirements

We will provide you with a quote for:

Essential Taxi Insurance

Which level of Excess do you require for motor?*

$1,000

$2,000

$5,000

Do you require Excess Free Windscreen Cover*

Yes

Public Liability cover

We will provide you with a quotation including $20,000,000 Public Liability cover as standard

$20,000,000

Loss History

Have you had any claims or unisured losses in the last 5 years?*

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).

Yes

Claim 1 Date of Loss*

Claim 1 Details*

Claim 1 Total Cost ($)*

Claim 1 Excess ($)*

Do you have another claim to record?

Yes

Claim 2 Date of Loss

Claim 2 Details

Claim 2 Total Cost ($)

Claim 2 Excess ($)

Have you had more than 2 claims?

Yes

Claim 3 Date of Loss

Claim 3 Details

Claim 3 Total Cost ($)

Claim 3 Excess ($)

Claim 4 Date of Loss

Claim 4 Details

Claim 4 Total Cost ($)

Claim 4 Excess ($)

Insurance History

Have you or any person applying for this insurance:

Been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property within the last 5 years?*

Yes

Been placed in bankruptcy, receivership or liquidation within the last 5 years?*

Yes

Had any insurer decline any claim or proposal, cancel or refuse to renew a policy, increase premium or impose special terms, conditions or restrictions on a policy within the last 5 years?*

Yes

Any other matter you should disclose to us, in relation to your duty of disclosure?*

Yes

If you have answered ‘Yes’ to any of the above, please provide details (attach separate sheet if required):

Driver Details

Have you or any intended driver ever:

Been fined or convicted of more than 3 speeding or other traffic offence (other than parking) within the last 3 years?*

Yes

Had a driving licence endorsed, suspended or cancelled within the last 5 years?*

Yes

Been convicted with Prescribed Concentration of Alcohol (PCA) or Driving Under the Influence (DUI) in the last 5 years?*

Yes

Suffered from any physical or mental condition which could affect their driving performance?*

Yes

Please upload any relevant documents

eg. 5 year Claims History, Insurance History or List of Vehicles

Drag and drop files here or

GT INSURANCE - IMPORTANT INFORMATION

DUTY OF DISCLOSURE

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 to Our 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 entitled to 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 of avoiding 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 Global Transport & Automotive Insurance Solutions Pty Ltd and Allianz Australia Insurance Limited trading as ‘GT Insurance'.

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.

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:

GT Insurance on (02) 9966 8820, EST 8.45am-5pm, Monday to Friday or by writing to GT Insurance, PO Box 1937, North Sydney, NSW 2059.

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, dispute resolution, statutory or regulatory bodies, and industry databases or as required by law.

Disclosure overseas

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 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:

GT Insurance on (02) 9966 8820 EST 8.45am-5pm, Monday to Friday, or by writing to Us at GT Insurance, PO Box 1937, North Sydney NSW 2059

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 www.gtins.com.au and www.allianz.com.au

Telephone Call Recording

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.

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.

GENERAL INSURANCE CODE OF PRACTICE

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.

GT Insurance on (02) 9966 8820 EST 8.45am-5pm, Monday to Friday, or by writing to Us at GT Insurance, PO Box 1937, North Sydney NSW 2059

For more information on the Code Governance Committee (CGC) go to https://insurancecode.org.au/

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.

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.

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.

THE INSURER

Allianz Australia Insurance Limited (incorporated in Australia); ABN 15 000 122 850; AFS Licence No. 234708 of 10 Carrington Street Sydney, 2000.

THE UNDERWRITING AGENCY

Global Transport & Automotive Insurance Solutions Pty Ltd (trading as GT Insurance) AFS Licence No. 240714 ABN 93 069 048 255 of Level 3, Suite 3.01, 213 Miller Street, North Sydney, NSW 2060 is an underwriting agency which specialises in arranging insurance in respect of Motor Vehicles and Mobile Plant and related insurances. GT Insurance acts as the agent of Allianz to market, solicit, offer, arrange and administer the insurance.

GT Insurance has a binding authority to issue, vary and cancel contracts of insurance and to deal with or settle claims on behalf of Allianz. If You need information about this insurance in the first instance, contact GT Insurance.

Declaration

I/We agree*

This declaration applies to all the insurance You are applying for in this Proposal. I/We hereby declare that:

• I/We have read the information concerning the Duty of Disclosure and other Important Notices;

• 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;

• upon acceptance the terms and conditions of this insurance will be in accordance with the Product Disclosure Statement and Policy Document;

• I/We have read and understood the Privacy Notice above and consent to the collection, storage, use and disclosure of any personal and sensitive information;

• an occurrence during the Period of Insurance, which alters any of the information provided, will be promptly notified;

• 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.

Yes

Completed by (full name)

Send me a copy of my responses

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