Carrier’s Transit Liability
A PPLI CAT I ON FORM
YOUR DUTY OF DISCLOSURE
You must tell us all information you know (or could reasonably be expected to know) which would influence the judgement of a prudent
underwriter whether or not to accept your application, and if it is accepted, on what terms and at what cost.
Examples of information you may need to disclose include:
Examples of information you do not need to disclose include:
`` anything that increases the risk of an insurance claim;
`` any criminal convictions in the last 7 years or where imprisoned;
`` if another insurer has cancelled or refused to renew insurance,
or has imposed special terms;
`` any insurance claim you have made in the past.
`` anything that reduces the risk of an insurance claim;
`` anything we say you do not need to tell us about;
`` anything that is common knowledge;
`` anything you have already told us, or that we should be
expected to know in the ordinary course of our business.
These examples are a guide only. If you are not sure whether you need to disclose a particular piece of information, please ask.
WHEN IN DOUBT – DISCLOSE. ALL INFORMATION WILL BE TREATED CONFIDENTIALLY.
CLIENT DETAIL
New client First name: Existing client Surname: POSTAL ADDRESS
Number/Street: Suburb: Town/City: CONTACTS
Business phone: Mobile: Private phone: Email: Website: Customer’s occupation: Date of birth: ANZSIC code (if known): CONTACT ADDRESS (IF DIFFERENT FROM ABOVE)
Number/Street: Suburb: Town/City: INSURED (IF DIFFERENT FROM ABOVE)
Name: Period of insurance from: Occupation (please tick): Carrier Consolidator
to: Wharfinger Customs Agent at 4pm
Other (please specify) Other occupation: 1. THE COVER
LIMITS OF INDEMNITY
1. Any one ‘unit of goods’ as defined in the Carriage of Goods Act, 1979.
2. Any one conveyance owned or operated by the Insured
3. Any one accident, i.e. any one occurrence or all occurrences of a series consequent on, or attributable to, one source or original cause.
EXCESS
Are you prepared to carry a larger excess than the standard $250? [Please tick] Yes No If ‘Yes’, please specify the amount Excess $ NZI MARINE CARRIER’S TRANSIT LIABILITY INSURANCE Application Form NZ8035/4 07/14
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Carrier’s Transit Liability / A PPL I CAT I O N FO R M
ENDORSEMENTS:
The policy excludes liability for loss of or damage to jewellery, gold and silver articles, precious stones, bullion, cash, banknotes, deeds,
bonds, bills of exchange and other documents representing money.
Do you wish this insurance to cover liability for such items? [Please tick] Yes No If ‘Yes’, please specify the items: Amounts
At limited carrier’s risk
At declared value risk
$ 2,000
$
$
$
$
$
2. THE BUSINESS
1. State the number and type(s) of vehicles operated by you: 2. Please tick if you carry any of the following:
Never
Occasionally
Frequently
Never
Machinery
Whiteware,
e.g. Refrigerators
Glass, china, etc
Brown goods, e.g. T.V.’s
Livestock
Vegetables and fruit
Refrigerated goods
Used H’hold &
Office removals
Occasionally
Frequently
3. State the main type of goods carried: 4. State the number of years the business has been established: 5. What percentage of freight earnings are derived from:
% of total
5.1 Urban deliveries
5.2 Inter-city movements within North or South Island
5.3 Inter-island movements
5.4 Rural deliveries
NZI MARINE CARRIER’S TRANSIT LIABILITY INSURANCE Application Form NZ8035/4 07/14
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Carrier’s Transit Liability / A PPL I CAT I O N FO R M
6. State the estimated gross income from your activities which are covered under the Carriage of Goods Act, 1979
$
Indicate the estimated percentage of your gross income from contracts where you act as:
%
6.1 Contracting carrier not actually carrying
6.2 The first actual carrier in the transit
6.3 An intermediate carrier in the transit
6.4 The final carrier in the transit
7. State in terms of the Carriage of Goods Act, 1979, the estimated percentage of gross annual income you contract:
% of gross income
7.1 At ‘Owners Risk’
7.2 At ‘Limited Carrier’s Risk’
7.3 At ‘Declared Value Risk’
7.4 On ‘Declared Terms’
NOTE: ‘Declared Terms’ contracts will be the subject of a separate insurance contract.
8. Consignment notes:
Attach a copy for each type of carriage contract. If a consignment note is not issued for each contract, please detail how the
terms of carriage are advised to clients.
3. THE APPLICANT AND OTHERS
1. Do you employ subcontractors? [Please tick] Yes No Yes No 1. Has any insurance company ever refused your application for insurance; or refused renewal of
your policy; or cancelled your policy; or required an increase in premium; or imposed special conditions?
Yes No 2. Has any insurance company ever refused your claim in respect of any insurance?
Yes No 3. Has any applicant, or any director or manager of any applicant been declared bankrupt or been
served with bankruptcy proceedings or been placed in receivership?
Yes No (a) ever been imprisoned for any criminal offence, or
Yes No (b) had any conviction for a criminal offence within the last 7 years, or
Yes No (c) any prosecution pending for any criminal offence?
Yes No 5. Are there any other policies held by the applicant covering the same insurance now applied for?
Yes No 6. Is there any further information which could influence our decision whether to accept this
application, or the terms of that acceptance?
Yes No If ‘Yes’, what percentage of your Gross Freight relates to sub-contractor loads? %
2. If sub-contractors are employed, is your liability as principal to be
covered whilst goods are in the custody of sub-contractors? [Please tick] INSURANCE HISTORY
4. Has any applicant or any director or manager of any applicant:
If you answered ‘Yes’ to any part of questions 1 to 6 please give details below, or on a separate page.
NZI MARINE CARRIER’S TRANSIT LIABILITY INSURANCE Application Form NZ8035/4 07/14
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Carrier’s Transit Liability / A PPL I CAT I O N FO R M
PRIVACY ACT STATEMENT
We gather information about you (including your claims history) to consider your application for insurance. Your duty of disclosure
requires you to do this. If you refuse to provide the information, we may decline your application or declare this policy unenforceable
from the beginning.
This information is held by us and you may access and seek correction of it. It may be passed on to other insurers you deal with, and
interested parties.
Your claims history is passed on to, and held by, Insurance Claims Register Ltd. This enables other insurers you deal with to access it,
and prevents fraudulent claims.
AGREEMENT
I agree that:
1. MATERIAL FACTS
(a) All information given to NZI (whether verbal or written) is true and correct;
(b) All material facts have been disclosed. (See ‘Your Duty of Disclosure’);
2. TERMS OF POLICY
The terms of NZI’s policy are accepted;
3. USE OF INFORMATION
(a) My personal information collected by NZI may be:
(i) used by NZI to advise me of its other services;
(ii) disclosed to other members of the insurance industry and Insurance Claims Register Ltd.,
and to parties who have a financial interest in the subject matter of the policy;
(b) My personal information held by other members of the insurance industry and Insurance
Claims Register Ltd., may be disclosed to NZI.
4.AGENCY Anyone who assists me to complete this Application Form is acting as my agent only.
Signed by the customer or customer’s broker or agent:
Signature: Name: Position (Director, Secretary etc.): Date: FOR OFFICE USE ONLY
Branch: Wording: Agent: Renewal type: Account no: Branch renewal act: Cover note no: Where filed: Repl. policy no: ANZSIC code: Client zone: No. vehicles: Service office: Transit chain code: Serviced by: Re-insurance or co-insurance: Master client: Excess $ NZI MARINE CARRIER’S TRANSIT LIABILITY INSURANCE Application Form NZ8035/4 07/14
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