UKAWA Pty Ltd ABN 59 009 357 582 trading as
ST.GEORGE
UNDERWRITING
AGENCY
75 North Lake Road, Myaree, W.A. 6154
P.O. BOX 3016, Myaree, W.A.6154
TEL: (08) 9317 8400
FAX (08) 9317 8499
AFS License No 236663

Application for
HOLIDAY HOME INSURANCE

Applicants are required to complete All sections in full
1. Applicant(s) name(s) in full
   
 
2. Applicant(s) Postal Address
       Post Code
 
3. Mortgagee or Other Interested Party
   
 
4. Address of Holiday Premises
       Post Code
     
5. Period of Insurance From To 4.00pm local standard time

Please read the following Important Information carefully before completing this application
YOUR DUTY OF DISCLOSURE  Before you enter into a contract of insurance with us, the Insurance Contract Act 1984 requires you to provide us with the information we need to enable us to decide whether and on what terms your application for insurance is acceptable and tocalculate how much premium is required for your insurance. You will be asked various questions  when you apply for this policy. When you answer these questions you must:
 
  • give us honest and complete answers,
  • tell us everything that you know, and
  • tell us everything that a reasonable person in the circumstances could be expected to tell us

You do not need to tell us about any matter:
 
  • that diminishes our risk,
  • that is common knowledge
  • that we know or should know as an insurer, or,
  • that we tell you we do not need to know.

TO WHOM DOES THE DUTY APPLY?  Everyone who is insured under the policy must comply with the relevant duty.

WHAT HAPPENS IF YOU OR THEY BREACH THE DUTY?  If you or they do not comply with the relevant duty we may cancel the policy or reduce the amount we pay if you make a claim. If fraud is involved, we may treat the policy as if it never existed and pay nothing.

DUTY ON RENEWALS, VARIATIONS AND REINSTATEMENTS  A new duty applies for any variation, renewal or reinstatement of the policy. Please refer to your Policy Document (Product Disclosure Statement) for this duty.

SUM INSURED  The total liability of the Company in respect to loss or damage caused by all or any of the Defined Events under the Company's policy shall not exceed the amount stated against each item respectively or in the aggregate the Total Sum Insured.

BASIS OF SETTLEMENT  Claims for loss or damage to property may be settled by payment or, at the Company's option, reinstatement, replacement or repair subject (unless otherwise specified) to due allowances for depreciation and betterment.

Amount of Insurance Required
6. BUILDING AND CONTENTS
  For how much do you wish to insure the Building and Contents?
    Sum Insured: Building (including fixtures & fittings) $
  Contents $
  Do you wish to insure any portable electronic goods? Yes No
    if "YES", please attach an inventory. Portable electronic goods are only covered if we list them on the Schedule.  
 
7. LOSS OF RENT
  Do you wish to insure against Loss of Rent from events for which the Buildings re insured? Yes No
    if "YES" what is the total Annual Rent for the insured premises $
 
8. STRATA TITLE MORTGAGEE'S PROTECTION
  Do you wish to insure for Strata Title Mortgagee's Protection? Yes No
    if "YES" what is the value of outstanding mortgage $
 
9. DELIBERATE DAMAGE BY TENANTS
  Do you wish to insure against Deliberate or Intentional Damage by Tenants? Yes No

Property Description
10. TYPE OF RENTABLE PREMISES  (Please tick all which apply)
 
    Unfurnished*
    Furnished
    Strata Titled
    * if building is unfurnished, please advise why
11. AGE OF BUILDING  
  If non-brick and over 40 years old, a writing certificate or Residual Current Device may be required)
12. SECURITY  
  Do all external doors have keyed deadlocks and all windows have keyed locks? Yes No
  (Please note the above-mentioned security is a condition of cover.)  
13. Name and Address of Managing Agent  
     
     
    Post Code  
14. TYPE OF DWELLING
    House   Townhouse   Unit   Flat   Resort Dwelling
15. CONSTRUCTION OF DWELLINGS WALLS
    Brick   Fibro   Asbestos**   Wood   Other
    ** if we agree to cover properties with asbestos walls or roof, the following endorsement will apply:
"We will not cover your legal liability for claims that would not have occurred but for the existence of asbestos."
16. Is the building structurally sound and well maintained? Yes No
    If "NO", please refer to St George Underwriting Agency.
 
17. Is the property for sale? Yes No
    (Cover is not available if the property is for sale by the Applicant)

Previous Losses/Insurance History
18. Has the proposer or any person or company interested in this insurance:
  (a) had any building or contents damaged or destroyed by fire, or had property lost or destroyed, due to burglary or theft or any other perils covered by this policy? Yes No
  (b) had any insurance proposal declined or any policy cancelled or renewal thereof refused? Yes No
  (c) had any renewal of building or contents insurance offered subject to special terms? Yes No
 
    If you have answered "YES" to any of these questions, please give full details including the names of the previous insurers.  
     

The Privacy Act 1988 contains National Privacy Principles which require us to tell you that as an agent for an insurer we collect, handle, store & disclose your personal and sensitive information in order to decide whether to issue a policy, determine the terms and conditions of your policy, compile data, and handle claims. In certain circumstances, we will disclose personal information to third parties with whom we deal to provide the relevant services and products. For example in handling claims, we may have to disclose your personal and other information to third parties such as other insurers, loss adjusters, investigators, agents, and others involved in the claims-handling process, or as required by law. We limit the use and disclosure of any personal information provided by us to them to the specific purpose for which it was supplied by us. You have the right to seek access to your personal and sensitive information and correct it at any time. To change information please contact us on (08) 9317 8400 WST 8.30am - 5.00pm and advise us of the changes. If you do not agree to the collection of your personal information then we will be unable to process your application.

DECLARATION

I/We am/are the person/s named as the applicant in this form.

This declaration applies to all the insurance you are applying for in this application. I declare that I have:

  • received a copy of the Policy Document (Product Disclosure Statement);
  • read the information concerning the duty of disclosure and other important notices;
  • answered every question fully & frankly;
  • either completed this application form personally or, if it has been completed by somebody else, I have checked that the questions have been fully and accurately answered.

If anything happens during the period of the insurance which alters any of the information I have provided, I will promptly inform St George Underwriting Agency.

I realise that if I have not complied with my duty of disclosure my claim may not be met.

By ticking the box marked "Yes, I agree" below, I authorise the insurer to:

  • obtain any information it may need about my claims and prior insurance history from my previous insurer(s);
  • make enquiries from third parties to verify claims history and other information ;
  • disclose my claims history to any insurance intermediary I appoint;
  • refer to the database of Insurance Reference Services Ltd to confirm the information I have supplied;
  • I acknowledge I have read and understood the Privacy Act 1988 information detailed above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons covered by this application.

By ticking  the box marked "Yes, I agree" below, I acknowledge that this questionnaire will form part of the contract of insurance and a copy will be sent to me with the policy document. I will be given the opportunity when the policy is issued to dispute the origin of the information above. Failure to lodge such a dispute within 30 days means that I unreservedly accept that the information may be relied upon by the insurer as being accurate.

Yes, I agree

Name of person ticking the box:
Your Email address: