Live Free
Ride Free
Motorcycle Insurance
NEIB MOTORCYCLE INSURANCE DECLARATION FORM
Quote Date
Quote No.
Policy No.
How did you hear about NEIB?
1. Contact Information (Broker or Client - Complete as relevant)
Name
Phone Numbers
Landline
Mobile
Client Occupation
Email Address
Postal Address
Postcode
2. Insured (Registered Owner)
Name
Years Licensed?
Date of Birth
(for this class of motorcycle or trike)
Years Experience
3. Rider Details (if not the Insured)
Name
Years Licensed?
Date of Birth
(for this class of motorcycle or trike)
Name
Years Licensed?
Date of Birth
(for this class of motorcycle or trike)
4. Finance
Is there any other party who has an interest in your bike / trike?
If "Yes", Name of Interested Party?
Type of interest held?
5. Underwriting Questions
In the last five (5) years have you or any other rider likely to use your motorcycle/trike:
a. Had an accident, fire, theft or malicious damage claim on a motor policy?
b. Had an insurance claim refused on any vehicle?
c. Had a vehicle insurance policy cancelled?
d. Been denied insurance or had a renewal refused?
e. Had their licence cancelled, amended or suspended?
f. Been convicted, fined or penalised for one or more drug or alcohol
related driving offences?
g. If “Yes” to question f, was there an accident involved with the
conviction or was any BAC reading greater than 0.15%?
h. Been convicted of a criminal offence in relation to fraud, arson or theft?
If "Yes" to any of the questions above, please provide details in Section 10 - Additional Information - below.
6. Period of Insurance
From:
To:
7. Bike/Trike Details
What type of Cover is required?
Year
Registration No
Make
Engine No
Model
VIN / Chassis No
Purchase Date
Sum Insured $
Purchase Price $
Odometer Kms
Are any accessories &/or modifications fitted to the motorcycle / trike?
If "Yes", please provide details in Section 10 - Additional Information - below.
Does the value of these accessories / modifications exceed 50% of a standard model?
What Security devices are fitted to the motorcycle?
How is the bike used?
(If Business Use , please provide precise description.)
How often is the bike/trike ridden?
(Please provide an estimated number of days used per week or per month as appropriate)
Garaging Address
Postcode
Is the motorcycle parked in a locked shed or garage at home overnight?
(If "No" please provide details in Section 10 - Additional Information - below. This may result in a decline.
Is the bike/trike ridden to work?
If "Yes" , where is the bike/trike parked at work?
What security devices are used or fitted to
your bike/trike or at work?
Is the motorcycle / trike maintained in a good, roadworthy condition, in working order and free from
mechanical defect and / or damage?
NEIB Category
NEIB Class
8. Sidecar / Trailer Details
Year
VIN / Chassis No
Make
Purchase Date
Model
Purchase Price $
Registration No
Sum Insured $
9. Policy Options
The following cover options are available for an additional premium. Would you like to include:
1. Hire another vehicle following an accident to your motorcycle or trike? (Silver only)
2. Airfreighting in of parts that are not readily available in Australia? $500 limit applies.
3. Do you wish to increase cover on your Personal Effects from $200 to $500? (Silver only)
4. Do you wish to increase cover on your Personal Effects from $1,000 to $2,000? (Gold only)
5. Do you wish to increase cover on your Riding Gear from $1,000? (Silver only)
6. Do you wish to increase cover on your Riding Gear from $4,000? (Gold only)
10. Additional Information
11. Important Information
The Underwriter: CGU Insurance Limited ABN 27 004 478 371 AFSL 238291
The Binder Licensee: New England Insurance Brokers Pty Ltd ABN 82 071 530 839
Cover issued under Live Free, Ride Free Motorcycle Insurance PDS:
Quotation Accepted:
Date Quotation Accepted:
12. Important Notices
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:
i. If the misrepresentation was fraudulent, we may avoid your Policy, or
ii. 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
www.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.
You may contact NEIB by Email [email protected],
Fax 07 4681 2427, Post to PO Box 358, Stanthorpe QLD 4380 or Call 1300 812 877.