Recommended by Scooti Pty Ltd

Underwritten by Insurance Australia
Limited T/A CGU Insurance

 

This form is ONLY for Scooti accredited riders.

[[[["field23","equal_to","Yes"]],[["show_fields","field17"],["show_fields","field20"]],"and"],[[["field22","equal_to","Yes"],["field24","equal_to","Yes"],["field25","equal_to","Yes"]],[["show_fields","field26"]],"or"],[[["field40","equal_to","Yes"]],[["show_fields","field41"]],"and"],[[["field45","equal_to","No"]],[["show_fields","field69"],["show_fields","field73"],["show_fields","field74"]],"and"],[[["field47","equal_to","No"],["field48","equal_to","No"]],[["show_fields","field49"]],"or"]]
1 Step 1
NEIB Scooter Insurance Declaration Form - Scooti Riders
1. Important Information

By submitting this form, in addition to the information you have provided herein and to Scooti during your application to Scooti, you confirm that you are the ONLY rider of this scooter and further, that in the last 5 years, you have NOT:

  • had more than one (1) motor vehicle accident whether reported or not;
  • made more than one (1) claim on any motor insurance policy;
  • incurred more than four (4) traffic infringements of any kind;
  • lost your licence for any reason.


You also declare that your application has been processed and accepted as a Scooti Rider by Scooti Pty Ltd, ABN 39 626 269 789.
This form can only be submitted if you are the ONLY rider of your scooter. If there are other riders, please call NEIB.

2. Contact Information
Insured Name
Home/Work
Mobile
Your Ocupation
Postal Address
Postal Suburb
Postal Postcode
3. Insured (Registered Owner Details)
Name
Years Licensed?(for this class of vehicle)
DOB
Years Experience
4. Finance
Interested Parties?Is there any other parties who has interest in your scooter?
If 'Yes'Name of Interested Party?
Type of Interest Held?
5. Underwriting - In the last five (5) years, have you:
a) Insurance ClaimHad a insurance claim refused on any vehicle?
b) Policy Cancelled?Had a vehicle insurance policy cancelled?
c) Denied Insurance?Been denied insurance or had a renewal refused?
Underwriting CommentsIf “Yes” to any of the questions above, please provide full details.
0 /
6. Period of Insurance
Date From:start date
date_range
Date To:renewal date
date_range
7. Scooter Details
Year
Make
Model
Purchase Date
Purchase Price
Registration Number
Engine Number
VIN / Chassis Number
Sum Insured
Odometer Reading(Kms)
AccessoriesAre any accessories &/or modifications fitted to the scooter? If “Yes”, please provide full details.
Accessories / ModificationsDescribe:
0 /
Security Device?What security devices are fitted to the scooter?
8. Garaging / Security Information
Garaging AddressSame as postal?
Garaging Addressif different from postal
Garaging Suburb
Garaging Postcode
Overnight storage?Is the scooter parked in a locked shed/garage or in a carport and fixed to an immovable object at home overnight?
Roadworthy?Is the scooter maintained in a good roadworthy condition, in working order and free from mechanical defect and / or damage?

(You selected “No” to Overnight or Roadworthy, this will result in a decline.)

'We are very sorry, but we cannot assist in circumstances where your scooter is left unsecured overnight at home.'

9. Additional Information
Additional Info(Additional Things You Need to Tell Us or where there has been insufficient space elsewhere)
0 /
10. Important Notices

The Underwriter: CGU Insurance Limited ABN 27 004 478 371 AFSL 238291

The Binder Licensee: New England Insurance Brokers Pty Ltd ABN 82 071 530 839AFSL 244247

When answering any questions, you must be honest.

We will use the answers you provide in deciding whether to insure you and anyone else to be insured under the policy, and on what terms.

Consequence of Misrepresentation

If you misrepresent any fact to us before your Policy is entered into and if we would not have entered into your Policy for the same Premium and on the same terms and conditions expressed in your Policy but for the misrepresentations, then:

  • If the misrepresentation was fraudulent, we may avoid your Policy, or
  • Our liability in respect of any claim may be reduced to an amount which would place us in the position in which we would have been but for your misrepresentation.

Who do these important notices apply to?

These important notices apply to you and to anyone else insured under the policy. If you provide information for someone else being insured, it is as if they provided it themselves.

Privacy

New England Insurance Brokers respects your privacy and complies with the requirements of the Privacy Act 1988 (Cth).  A copy of our Privacy Statement and Privacy Policy is available at our office or online at neib.com.au.

Payment and Declaration

  • Your payment for the premium of this Policy or a request for an interim cover will represent the following:
  • You have received the Product Disclosure Statement (PDS) and accepted to be bound by the terms and conditions contained in it.
  • You have read and understood the Important Notices set out above.
  • You have authorised CGU/New England Insurance Brokers to give to or obtain from Insurers or insurance reference bureaus any information about your insurance and claims history and any other information relating to this insurance if required at any time.

Policy Information

This declaration forms part of your contract of insurance. You should keep it in a safe place for future reference. If any information shown is inaccurate or incorrect, please contact NEIB immediately.

Acknowledgement & Submit

I acknowledge that I have read and understood the important information in Section 1 and important notices in Section 10 and all my answers are true and correct.

I Acknowledge
Nameyour full name
keyboard_arrow_leftPrevious
Nextkeyboard_arrow_right
FormCraft - WordPress form builder