Insurance application form

It is mandatory as part of your novated lease to have your vehicle fully comprehensively insured with an insurer of your choice. If you wish to receive a quotation for comprehensive motor vehicle insurance with Allianz Australia Insurance Limited (AFSL 234708) ABN 15 000 122 850 (Allianz) as part of your novated lease arrangement, please complete the section below. Maxxia is an authorised representative of Allianz.

The following questions should be answered carefully and in full by the novated lease lessee only. The lessee will be listed as the primary driver under the insurance policy, regardless of whether the lessee is the majority driver. The policy generally covers other drivers of the vehicle, although additional excesses may apply depending on driver age. The information on this form will be used to provide you with a quotation and, if you purchase insurance, will form part of your contract with the insurer. Should you proceed to purchase this policy, the start date of your insurance coverage will coincide with the date that you take delivery of your vehicle.

Note: An at fault claim is any claim where you were required to pay an excess, including claims resulting from weather (eg. hail damage), wildlife, and/or where the third party responsible was not identified

3. In the last 3 years, have you or any person who will or is likely to drive any of the vehicles listed:

Maxxia is committed to protecting your privacy. The information you provide is used by the insurer to assist in deciding whether to insure you and on what terms. Maxxia and not a third party provides your information to the insurer (and their representatives). The insurer may exchange this information with other insurers or insurance reference services. Maxxia may also use your information to provide you with updates about other products and services, including financial products and services. Maxxia do not trade, rent or sell your information. You can check the information Maxxia hold about you at any time. For more information about our Privacy Policy, ask us or refer to www.maxxia.com.au.

Declaration by the applicant
1. I have read and understood my Duty of Disclosure as detailed in the Product Disclosure Statement (PDS).
2. I declare to the best of my knowledge and belief that the information given on this form is true in every respect.
3. I agree that this application and declaration shall form part of the contract between myself and the insurer.