TCIS Insurance Brokers Pty Ltd

Camper Trailer & Camping Equipment Insurance Application
Please use your TAB key to advance through the application form. Click the submit button at the bottom of the page to email your application to our team. Please complete all fields unless otherwise indicated.
Section 1: General Details
*Registered Owner(s):
Telephone Details:
Mobile:
Home:
Work:
Fax:
*Email Address :
*Postcode :
Best Contact Point:
Name of 4WD Club (if member) :
*Date of Birth of Registered Owner 1:
yrs
 Date of Birth of Registered Owner 2 (if applicable):
yrs
Section 2: Camper Trailer Details
Registration No:
Chassis No :
Year of Manufacture:
Make and Model of Camper Trailer
(full description):
Current Vehicle Value: $
+ Current Options & Accessories: $
= Total Current Sum Insured: $
Section 3: Camping Equipment Details
Please tick amount of cover required: $2500 $5000 $7500 $10000
Please list any camping equipment items valued over $500:
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Item:
Approx. Age:
Approx. Value: $
Period of Insurance Required: Commencing:
/
/
Expiring:
/
/
Has, or is, any regular driver(s):
(a) *Under 21 years of age?
Yes No
(b) *Lost their licence in the last 5 years?
Yes No
(c) *Had motor insurance declined, cancelled or renewal refused?
Yes No
(d) *Had any motor claims or other losses in the last 5 years?
Yes No
(e) *Had any insurer require special terms?
Yes No
(f) *Used/ing the vehicle in any business or commercial activities?
Yes No
(g)*Been charged, convicted or penalised for any motoring offences?
Yes No
(h) *Been charged or convicted of any criminal offences in the last 10 years?
Yes No
(i) *Are there any exceptional circumstances relating to the risk, which may affect our decision to insure you ?
Yes No
If yes to any of the above, please provide details:
IMPORTANT MATTERS REFERRED TO IN THE INSURANCE CONTRACTS ACT 1984
1. YOUR DUTY OF DISCLOSURE

Before you enter into a Contract of General Insurance with us, you have a duty under the Insurance Contracts Act 1984, to disclose to us every matter you know, or could be reasonably expected to know, that is relevant to our decision whether to accept the risk of the insurance an, if so, on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate your insurance.
Your duty does not, however, require disclosure of matters:

(a) that diminish the risk to be undertaken by us;
(b) that are of common knowledge
(c) that we know, or in the ordinary course of business, ought to know;
(d) as to which compliance with your duty is waived by us.
2. NON-DISCLOSURE

(a) The statements in the Application Form are true.
(b) I/We have disclosed all matters of which, to my/our knowledge, you should be aware.
(c) No Insurance Company has ever cancelled, declined, or refused to renew, or imposed special terms or conditions, on any policy held by me/us.
(d) The I/We agree to accept the terms, exclusions, conditions and limitations of the Insurance Contract.
In relation to Caravan or Camper Trailer Insurance proof of No Claim Bonus must be submitted prior to placement of cover. This may be faxed to us on 08 8278 8555 if cover is urgently required. Original must be posted, accompanied by payment to: PO BOX 425, Blackwood, SA 5051