Rural
I N S U R A N C E A P P L I CAT I ON FO R M
Agent name: Policy number 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.
DETAILS OF APPLICANT(S)
New client Existing client APPLICANT 1
First name: Surname: Occupation: Date of birth: ANZSIC code (if known): APPLICANT 2
First name: Surname: Occupation: Date of birth: ANZSIC code (if known): If the applicant is a Body Corporate, Trust or Company, please provide the following information on a separate sheet and attach to the application form:
Body Corporate – Details of all unit proprietors and mortgagees, Trust – Detail of Trustees, Company – Details of Owners and Directors.
POSTAL ADDRESS
Number/Street: Suburb: Town/City: CONTACTS
Telephone: Covers already with NZI: Mobile: None Email: House Contents Car Boat Business Please provide the name of any Company or Trust that you own and insure with NZI: Period of insurance from: to: at 4pm
Farm location (a): Farm location (b): Any non farm activities?
Yes No If ‘Yes’, please supply details: Farm supply number (for dairy): PAYMENT OPTIONS
How do you wish to pay?
Annually NZI RURAL INSURANCE Application Form NZ705/14 04/13
Quarterly* Monthly* *Please complete the Flexisteps Pay Plan form
PAGE 1
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L M AT ERI A L DA M AGE
Excess
Standard $500 Voluntary $1,000 $2,500 $5,000 Insured property – buildings
Year
built
Construction
Replacement
value $
Indemnity
value $
Size sqm
Cover*
1980
Concrete and steel
$20,000
$15,000
200
S
1
$
$
2
$
$
3
$
$
4
$
$
5
$
$
6
$
$
7
$
$
8
$
$
9
$
$
10
$
$
$
$
$
$
11
Code
Description
RV1
Example
implement shed
003
Sundry buildings – limit $7,500
per building
Sum insured – buildings
Office Use Only
Rate
Prem
Govt
levy
*Cover Types
T = Full Replacement Value (sqm) S = Replacement Value I = Actual Value (Indemnity)
Full Replacement Value cover is not available for all buildings.
Replacement value codes
Full replacement value
RV1
Farm Buildings
FR1
Farm Buildings
RV2
Milking Sheds
FR2
Milking Sheds
RV3
Coolstores
FR3
Coolstores
RV4
Grainstores/Poultry Sheds
FR4
Grainstores/Poultry Sheds
RV5
Greenhouses
FR5
Greenhouses
RV6
Horticultural Buildings
FR6
Horticultural Buildings
RIN
Indemnity Value
FIN
Indemnity Value
REX
Excess of Indemnity
FEX
Excess of Indemnity
Insured property – other assets, produce, animal feed
Code
Description
Replacement
value $
Indemnity value $
Cover
Office Use Only
Rate
12
009
Other assets – contents of buildings, machinery, plant, tools,
general stores, wool or milk
$
$
S
13
004
Animal feed – hay, straw, lucerne
$
$
S
14
017
Produce
I
$
$
15
$
$
16
$
$
17
$
$
Sum insured other assets, produce, animal feed
$
$
NZI RURAL INSURANCE Application Form NZ705/14 04/13
Prem
Govt
levy
PAGE 2
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
Insured property – additional covers
Code
Description
Standard cover
Sum insured
$
Office Use Only
Rate
18
018
Artificial Windbreaks
$5,000
$
19
CUL
Culverts
$5,000
$
20
VEL
Deer Velvet
$5,000
$
21
013
Fences Cover
$5,000
$
22
PMP
Submersible Pumps
$7,500
$
Standard cover
Sum insured
Prem
Govt
levy
Insured property – optional covers
Code
Description
Office Use Only
Rate
23
CEC
Natural Disaster
24
SRC
Additional Sustainable Rebuilding Costs
25
BRG
Bridges or Underpasses
Prem
Govt
levy
$
$
26
IRR
Irrigation Equipment
27
LPE
Live Plants
$
28
007
Livestock
$
29
MLK
Milk Benefits
$10,000
30
GIT
Produce, goods and livestock in transit
$25,000
31
STT
Standing Timber
$
32
ORC
Orchard Trees
$
Additional covers
Animal Feed in Open
Bulk Fertiliser in Open
Capital Additions Cover $50,000
Demolition Costs Cover
Electric Fusion Cover $7,500
Employee Effects Cover $5,000
Expediting Costs Cover
Fees and Other Costs
Hazardous Substance Emergency $10,000
Increased Cost of Working $25,000
Increased Cost of Working – Sharemilker $25,000
Liquidation Bankruptcy and Receivership Protection $10,000
Money Extension $2,500
Property Under Construction $50,000
Protections Costs Cover $25,000
Refrigerated Supplies $3,000
Rewards Cover
Rural Service Utilities Cover $10,000
Stolen Keys Cover $10,000
Unharmed Property
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 3
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L B US I N ES S I N T ERRUPT I O N
SUM INSURED
Code
Cover
Material damage
INP
Loss of Insured Profit
(Including increased cost of working)
REV
Loss of Revenue
RRV
Loss of Rents
weeks, plus
Dual wages – 100% for
the balance with the
option to consolidate to
weeks
WLN
Wages in lieu of notice
weeks
PDB
Dual Payroll – 100% for
the balance with the
option to consolidate to
weeks, plus
PFB
Payroll
AEW
Additional Increased Cost of Working
CPC
Claim Preparation Costs
232
Book Debts
ROR
Rewriting of Records
DWB
Natural disaster
Sum insured
Rate/Premium
Sum insured
Rate/Premium
$
$
$
$
%
%
weeks
TOTALS
Indemnity period
6 months 9 months Include Machinery Breakdown Extension? Yes 12 months Other: Months
No Note: A sum insured calculation sheet for Business Interruption is available at the rear of this application.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 4
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L M AC H I N ERY B R EA KDOWN
Unspecified machinery
Electrical and mechanical plant that:
is less than 5 kw (6.75 hp)
has an individual replacement value of less than $2,500
Number of machines
Sum insured
$
Office Use Only
Rate
Premium
Specified machinery
Code
Year
Description
Sum Insured
Office Use Only
Rate
202
$
202
$
202
$
202
$
Premium
Additional policy extensions
Office Use Only
Rate
PMP
Submersible Pump
$
PMP
Submersible Pump
$
205
Expediting Costs
$
Excess
Standard $500 NZI RURAL INSURANCE Application Form NZ705/14 04/13
Premium
Voluntary $1,000 PAGE 5
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L STOC K D ET ERI ORAT IO N
Code
Description of stock
(Produce, bulbs, semen straws etc)
Type of storage
chamber
Cryogenic extn
Sum insured
(current value)
Yes No $
Yes No $
Yes No $
Yes No $
Office Use Only
Rate
Co. Premium
Total Sum Insured
Standard Excess: 10% Voluntary Excess: 20% 30% 50% Does the sum insured for stock represent full current value?
Yes No (a) maintained by your own engineering staff?
Yes No (b) the subject of a regular maintenance contract? Yes No (c) connected to a monitored automatic alarm system?
Yes No Do you store goods belonging to others?
Yes No Is there a reserve generator, or alternative storage facilities, available?
Yes No Note: It is a requirement of this insurance that all the refrigerated stock must be insured for its replacement value. In the event of under insurance, the Insured will be required to be their own insurer for the difference.
Is the refrigerating machinery:
Note: The refrigeration machinery must be insured under a NZI Machinery Breakdown policy.
UNDERINSURANCE
1. Your insurance policy contains a provision making them subject to average.
2. That provision will have effect only if the property insured under the policy is underinsured at the time of loss.
3. If the property insured under the policy is underinsured at the time of loss, the following will apply:
(a) if you suffer total loss, the provision will have no effect.
(b) if you suffer a partial loss, the maximum amount you may recover will bear the same proportion to your actual loss as the amount
for which the property insured bears to the full value of the property.
(c) whatever your loss, in no case will you be entitled to recover more than the amount for which the property is insured.
For example: Your property is worth $20,000. You insure it for $10,000. You suffer a loss of $5,000. If your policy is subject to average,
the maximum amount you may recover will be $2,500.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 6
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L L I A B I L I T Y
BROADFORM LIABILITY
Annual turnover
Annual wages
$
$
Number of employees
Office Use Only
Cover:
Other $
$2,000,000 $1,000,000 Excess $500
Is a voluntary excess required? $1,000 Number of years on farm
$2,500 Premium
No Yes $5,000 Automatic extensions
Agricultural Contracting – $250,000
Bailees Liability – $250,000
Defective Design Liability – $250,000
Errors and Omissions Liability
Exemplary Damages – $1,000,000
Farmstay Liability
Food Poisoning of Animals – $250,000
Forest and Rural Fires Act – $250,000
Hunt Club Meetings
Landlords Liability
Loading and Unloading Liability
Mechanical Mobile Plant Liability
Motor Repair or Storage Liability – $250,000
Pollution Liability
Product Withdrawal Costs (NZ only) – $100,000
Roadside Grazing
Underground Services Liability
Removal of Support – $250,000
Welding, Gas Cutting, Burning off Liability
Office Use Only
Do you require cover under the Forest and Rural Fires Act in excess of the
standard $250,000? $500,000 $1,000,000 Yes No Premium
$2,000,000 Have any circumstances in the last 5 years occurred that could result in a claim under
this cover that you are applying for?
Yes No Yes No Yes No Yes No Yes No If ‘Yes’, please give details below and/or on a separate page:
Do you ever undertake any work away from your farm?
If ‘Yes’, please give details below and/or on a separate page:
Do you ever look after property not belonging to you? e.g. animals, produce, machinery?
If ‘Yes’, please give details below and/or on a separate page:
Do you undertake contracting work?
If ‘Yes’, what percentage of your annual turnover is obtained from contracting?
Does your contracting work ever involve non agricultural activities?
%
If ‘Yes’, please give details below and/or on a separate page:
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 7
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
STATUTORY LIABILITY
Standard Cover: $500,000
Is additional cover required?
Yes Office Use Only
No Premium
$1,000,000 Excess: $500
Is a voluntary excess required? $1,000 $2,500 Yes No $5,000 Have any circumstances in the last 5 years occurred that could result in a claim
under this cover that you are applying for?
Yes No If ‘Yes’, please give details below and/or on a separate page:
Resource Management Act
Do you need, or have you ever applied for a resource consent and/or a certificate of compliance
under the Resource Management Act? Yes No Yes No Yes No If ‘Yes’, please give details below and/or on a separate page:
Animal Products Act and Animal Welfare Act
Have you ever been involved in any investigation or proceedings under, or had compliance
notices served upon you, or had fines imposed upon you for any breach of either the
Animal Products Act or the Animal Welfare Act? If ‘Yes’, please give details below and/or on a separate page:
EMPLOYER’S LIABILITY
Standard Cover: $500,000
Is additional cover required?
Yes Office Use Only
No Premium
$1,000,000 Excess: $500
Is a voluntary excess required? $1,000 $2,500 Yes No $5,000 Number of employees: Full time:
Part time:
Seasonal:
Have any circumstances in the last 5 years occurred that could result in a claim
under this cover that you are applying for? If ‘Yes’, please give details below and/or on a separate page:
ACC
Are you an ‘exempt’ or ‘accredited’ employer under current ACC legislation? Exempt Accredited Annual ACC levy: $
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 8
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L C OM M ERC I A L M OTOR
Gross Vehicle Weight or CC Rating: For cars, utes, vans and light trucks up to 3,500kgs, please provide the engine cc rating (e.g. 2000cc).
For trucks, trailers, mobile plant over 3,500kgs, please provide the gross laden weight (GLW).
Gross laden weight means the vehicle weight plus load capacity.
Cover Type: Please indicate which cover is to apply in the cover column above:
C = Comprehensive.
F = Third Party, Fire Theft and Illegal Conversion.
T= Third Party only.
Item
no.
Year of
manufacture
Make, model and type
of vehicle
Rego. no.
Gross laden
weight or cc
rating
Market
value
1
$
2
$
3
$
4
$
5
$
6
$
7
$
8
$
9
$
10
$
Cover
type
NCB
Office Use Only
Rate
Govt
levy
Prem
OPTIONAL EXTENSIONS
TICK where required. Please refer to policy wording for full definitions of extension. If an increase to the standard policy limits is required,
please provide details.
Item
303
Foreign Objects
312
Contracting
SMP
Agreed Value – Specialist Mobile
Plant Only (Valuation Required)
AMP
Appreciation – Mobile Plant Only
RFC
Liability for Rental Vehicles
(Full Cover)
RRE
Liability for Rental Vehicles
(Restricted Cover)
1
2
3
4
5
6
7
8
9
10
Excess: $400
Is a voluntary excess required?
$1,000 Yes No $2,500 $5,000 NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 9
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
VFT codes
Cover
VFO codes
Trucks
Utes
Cover
Tractors
Plants and
Implements
Unspec.
Vehicles
Bikes
FULL
R3E
R3F
FULL
R4A
R4B
R4J
R6A
TPFT
R3Z
R3Z
TPFT
R4Z
R4Z
R4K
R6Z
TPO
R3X
R3X
TPO
R4X
R4X
N/A
R6X
1. Are any of the vehicles ever used for anything other than farming, social or domestic use?
Yes No 2. Are any of the vehicles designed and used for bulk transportation of inflammable liquids or gases?
Yes No 3. Do you carry toxic chemicals, acids, explosives or items considered dangerous?
Yes No 4. Do you hire out any of your vehicles without your driver?
Yes No 5. Are any vehicles used, or intended to be used, airside at any airport?
Yes No 6. Are the vehicles fitted with any anti-theft devices or fire extinguishers?
Yes No 7. Has any vehicle been altered from the manufacturer’s original specifications?
Yes No Yes No Yes No If you answered ‘Yes’, to any of questions 1 to 7 above, please give details below and/or on a separate page.
8. Where are the vehicles normally housed when not in use? (i.e. locked garage, locked yard, etc.)
DRIVER HISTORY
1. Have you previously held motor vehicle insurance?
If ‘Yes’, please list all insurers for the last 5 years:
Insurance company
Branch
Period from
Period to
Policy (if known)
2. Have you had any motor accidents, claims or losses, whether or not the subject of an insurance claim,
in the past 5 years?
Date of accident
Description of accident
Insurance Company
Total cost
3. Have you, or anyone else who will drive the vehicles:
(a) Ever been charged with a log book offence?
Yes No (b) Ever had a driver’s licence endorsed, suspended or cancelled?
Yes No (c) Ever been indefinitely disqualified from driving for repeat alcohol or drug related offences?
Yes No If you answered ‘Yes’, to any part of question 3, please give full details below and/or on a separate page:
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 10
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L I N C OM E P ROT EC T I O N
Full name
Occupation
D.O.B
Height
Weight
Smoker
Person 1.
Yes No Person 2.
Yes No Cover taken: person 1
Office Use Only
Code
Benefit
Taken
DTH
Death Cover
Yes No $
PDS
Permanent Disability
Yes No $
FDY
Temporary Total Disablement (Injury)
Yes No $
PDI
Temporary Partial Disablement (Injury)
Yes No $
FDS
Temporary Total Disablement (Illness)
Yes No $
MEX
Medical Expenses
Yes No $
Employment of Temporary Staff
Yes No $
Deferment Period:
1 week (standard) Voluntary Period: 2 weeks 4 weeks Sum Insured
8 weeks Cover taken: person 2
Office Use Only
Code
Benefit
Taken
DTH
Death Cover
Yes No $
PDS
Permanent Disability
Yes No $
FDY
Temporary Total Disablement (Injury)
Yes No $
PDI
Temporary Partial Disablement (Injury)
Yes No $
FDS
Temporary Total Disablement (Illness)
Yes No $
MEX
Medical Expenses
Yes No $
Employment of Temporary Staff
Yes No $
Deferment Period:
1 week (standard) Voluntary Period: 2 weeks Premium
4 weeks Sum Insured
Premium
8 weeks Medical Authority: Person 1
Doctor: Address: I authorise you to give NZI any medical information you have regarding me.
Signature: Date: Medical Authority: Person 2
Doctor: Address: I authorise you to give NZI any medical information you have regarding me.
Signature: Date: NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 11
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
Medical History: Person 1
Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory,
or respiratory systems; cancer; arthritis or rheumatism; back or spine complaints; hernia; diabetes;
abnormal blood pressure; or heart disease?
Yes No Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned?
Yes No Are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent
medical condition or complaint, or have you any physical defect, disability or impairment?
Yes No Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind?
Yes No Have you ever used or injected yourself with any drug not prescribed by a doctor?
Yes No Have you ever been on a programme of drugs, pills or other medication?
Yes No Have you ever had any disorder relating to menstruation or pregnancy?
Yes No Are you pregnant?
Yes No Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory,
or respiratory systems; cancer; arthritis or rheumatism; back or spine complaints; hernia; diabetes;
abnormal blood pressure; or heart disease?
Yes No Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned?
Yes No Are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent
medical condition or complaint, or have you any physical defect, disability or impairment?
Yes No Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind?
Yes No Have you ever used or injected yourself with any drug not prescribed by a doctor?
Yes No Have you ever been on a programme of drugs, pills or other medication?
Yes No Have you ever had any disorder relating to menstruation or pregnancy?
Yes No Are you pregnant?
Yes No If ‘Yes’, expected date of delivery: If you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:
Medical History: Person 2
If ‘Yes’, expected date of delivery: If you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 12
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
RUR A L L I V ESTOC K
WORKING DOGS
Unspecified Working Dogs
Office Use Only
Rate
Number of dogs:
Co. Premium
@ $750 per dog = Sum Insured $ Specified Dogs
Name
Gender
Age*
Illness and
disease extn
Sum insured
M/F
Yes No $
M/F
Yes No $
M/F
Yes No $
M/F
Yes No $
*Note: the policy applies an age limit on the dogs covered of 4 months to 9 years.
WORKING HORSES
Code
Description of horse
Gender
Age*
Sum insured
M/F
$
M/F
$
M/F
$
M/F
$
M/F
$
Total Sum Insured
$
Office Use Only
Rate
Co. Premium
*Note: the policy applies an age limit on the horse covered of 12 months to 14 years
Are the horses in good health and free from injury, disability, physical abnormality or illness?
Yes No Have any of the horses suffered from any unsoundness or illness in the last 12 months?
Yes No If ‘Yes’, please give details:
Note: A veterinary certificate of health must be obtained for any horse valued over $5,000.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 13
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
LIVESTOCK
Cover selected:
Code
Individual animal Description
Species
Herd cover* Gender
Age
Transit only cover Sum insured
M/F
$
M/F
$
M/F
$
M/F
$
Total sum insured
$
30 day cover Office Use Only
Rate
Co. Premium
* Please attach a schedule of the animals to be insured.
Additional cover
Office Use Only
Code
Extension
707
Tuberculosis
Yes No 702
Dehorning and Velveting
Yes No 709
Theft and Escape
Yes No 713
Unborn Offspring
Yes No Rate
Co. Premium
Are the animals in good health and free from injury, disability, physical abnormality or illness?
Yes No Have any of the animals suffered from any unsoundness or illness in the last 12 months?
Yes No Yes No If ‘Yes’, please give details:
Were the animals brought at auction during the last 12 months?
Note: A veterinary certificate of health may be required for any animal not bought at auction during the last 12 months.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 14
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
HO US E
Indicate cover chosen:
NZI Echelon NZI Essence NZI Houseowners Replacement Value NZI Houseowners Present Value ADDRESS OF PROPERTY
Number/Street: Suburb: Town/City: Post Code: What is the source of water supply?
Reticulated water supply tank/bore HOME STRUCTURE
What type of home is this? Freestanding house Semi-detached Flat/unit Apartment Body corporate Is the home fully self contained? (Self contained means that the home has its own functional kitchen and bathroom facilities).Yes No How many self contained dwellings are to be insured by this policy? How many self-contained dwellings are there in the building? What is the main building material for outside walls?
Double brick Brick veneer Concrete block Fibre cement (fibro) Mud brick Cement Metal Rockcote/EPS Rock/stone Timber/weatherboard Other Number of storeys: Year Built: If built before 1935: Have any of these been done in the last 30 years?
CONSTR
B/O
All electrical wiring replaced
Yes No Roof completely replaced
Yes No All plumbing replaced
Yes No All walls re-lined with Gib Board
Yes No Completely re-piled
Yes No Does the home have a Historic Places Trust classification?
Yes No Does the council identify the home as a heritage building, or that it is in a heritage zone? Yes No OFFICE
USE ONLY
If you have answered ‘Yes’ to any of the above, please provide additional information below, such as dates renovations were carried out, etc:
FLOOR AREA
Please provide the floor area of:
`` the home including all levels, attached garage, conservatory and developed basement sq metres
`` any detached garage and outbuildings (over 10sqm each) sq metres
`` the decking
sq metres
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 15
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
SUM INSURED
HOME SUM INSURED
If NZI ECHELON, NZI ESSENCE OR NZI HOUSEOWNERS REPLACEMENT VALUE cover has been selected:
What is the estimate of the likely cost to rebuild the home and domestic outbuildings in today’s prices?
This should include any increased policy limits for retaining walls and Recreational Features below,
allowance for inflation, demolition, and fees associated with rebuilding. $
If NZI HOUSEOWNERS PRESENT VALUE cover has been selected:
What is the present value of the home, including any increased policy limits below, but not including
the value of the land? $
Within the Home Sum Insured the following levels of cover apply:
NZI ECHELON
NZI ESSENCE
NZI HOUSEOWNERS
Retaining Walls (Total all items)
$25,000
no cover
no cover
Recreational Features* (Total all items)
$45,000
no cover
no cover
*Any tennis court and/or permanent fixed swimming pool or permanently fixed spa pool including its ancillary equipment
and/or pump(s).
Do you wish to apply for cover above the levels shown above?
Yes No If ‘Yes’, please provide details of the items (e.g. construction materials, dimensions, condition and age of
each structure) along with the likely cost to rebuild them:
$
$
$
SPECIAL FEATURES’ SUMS INSURED
Does the property have any Special Features listed below for which you would like cover under this policy?
Bridge, culvert, permanent ford or dam Wharf, pier, landing or jetty Cable car and its associated equipment Private utility plant and associated equipment (e.g. wind mills) If ‘Yes’ to any of the above, please provide details of the items (e.g. construction materials, dimensions,
condition and age of each structure) along with the likely cost to rebuild them:
SPECIAL FEATURE SUM INSURED
$
$
$
$
$
TOTAL SUM INSURED
The Total Sum Insured is the sum of the Home Sum Insured and any Special Features’ Sums Insured (above).
A. Home Sum Insured
$
B. Special Features’ Sums Insured
$
Total Sum Insured (A+B)$
This is the maximum amount payable to repair or rebuild your home.
If:
`` the estimated cost to rebuild the home and domestic outbuildings exceeds $2,000,000 and/or
`` the floor area of the home, garage(s) and outbuildings exceeds 500sqm,
has a Valuation for Insurance Purposes been completed for the home in the last 4 years?
Yes No If yes, please provide a copy along with this application.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 16
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
OCCUPANCY
Who lives in the home?
Owner & family Owner & tenants Owner & boarders Tenants Owner’s relative/employee Owner’s holiday home Holiday home to let Retirement village unit Does more than one tenancy agreement operate at the property?
Yes Unoccupied No If ‘Yes’, how many? Is any part of the property ordinarily available for periods of less than 28 days?
No Yes FOR TENANTED PROPERTIES ONLY
1. Who manages the property?
Owner Property Manager 2. Is the interior inspected by the owner or a property manager less frequently than once every 3 months?
Yes No 3. Has there been any damage by tenants (whether insured or not) in the past 5 years?
Yes No Yes No If ‘Yes’, to question 2 or 3, please give details below (include date and approximate cost for question 3).
4. Do you want to purchase the Optional Additional Benefit – Landlord’s Protection?
(This option is only available under NZI Echelon)
5. What is the weekly rental amount? $
The cover on a tenanted property has a higher standard excess and is subject to specific conditions. Please refer to the policy wordings for full details.
GENERAL QUESTIONS
Is any part of this property used for any business, trade or profession,
other than as a home office or residential rental property?
Yes No Is any part of the property damaged or in need of repair?
Yes No Is any part of the property undergoing renovation or alteration, or that is partially built?
Yes No Has the property been identified by the council as being at risk from any natural hazard,
such as flooding or inundation, erosion or subsidence? This would be identified in the
‘Land Features’ section in a LIM report or similar document. Yes No If you have answered ‘Yes’ to any of the above, please provide additional information below:
Is the home watertight, structurally sound, secure and well-maintained?
Yes No If ‘No’, please provide details below:
NMIB
N200
MULTI
002$
023$
Y
Y
Y
Y
Y
N
N
N
N
OFFICE
USE ONLY
N
POLICY EXCESS
NZI Echelon and Houseowners
Standard Excess $400 Plus additional Voluntary Excess (with Premium Discount)
$350 $850 $1,600 Plus additional Voluntary Excess (with Premium Discount)
$250 $500 $1,000 NZI Essence
Standard Excess $500 NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 17
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
MORTGAGEE DETAILS
Please provide details of any mortgage interests to be noted including the name and postal address. If the applicant is a Body Corporate,
please provide details of all unit proprietors and mortgagees on a separate sheet and attach it to the application.
C O NT E N T S
Indicate cover chosen:
NZI Echelon NZI Essence NZI Householders ADDRESS WHERE CONTENTS KEPT
Number/Street: Suburb: Town/City: The property that the contents are in, is occupied by:
Its owner The owner as a holiday/weekend home A tenant (sharing with non family members) An employee/relative of owner A tenant (alone or with family) A tenant, but contents insured by the owner If you own the home the contents are in:
Has your property been identified by the council as being at risk from any natural hazard, such as flooding or inundation, erosion or subsidence? This would be identified within the
‘Land Features’ section in a LIM Report or similar document.
No Yes If ‘Yes’, please provide additional information below.
WHO WILL BE COVERED? This insurance will cover Contents owned by the person making this application, and their husband or wife, or
person with whom they are living in the nature of a marriage and their family who live at the address above.
Yes No Is the house fitted with a burglar alarm?
Yes No Does it include an external siren?
Yes Is Insurance required for Contents owned (or jointly-owned) by anyone else? (eg. grandparents etc).
If ‘Yes’, you must give their details below or their contents will not be covered.
SECURITY
No OFFICE
USE ONLY
NALX
Y
Was it fitted professionally?
Yes Is it professionally monitored?
Yes N
No No OFFICE
USE ONLY
NALM
Y
N
Do all external doors have deadlocks?
Yes No Do all accessible external windows have keyed window locks?
Yes No Is there a permanently fixed safe installed at the home?
Yes No NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 18
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
POLICY LIMITS
1.
Watch or item of jewellery
2.
Camera and photography equipment (including video)
3.
Bicycles
Items
NZI Echelon
NZI Essence
Householders
any item
$3,000
$3,000
$1,500
total all items
$15,000 (jewellery)
$10,000
$10,000
any item
$3,000
$2,000
$1,500
total all items
No Limit
No Limit
$3,500
any item
$2,000
$2,000
$1,000
4.
Money, vouchers, bullion, unset precious stones
total all items
$1,000
$750
$250
5.
Home office furniture and equipment (while at the home)
total all items
$10,000
Not covered
$1,000
6.
Ornament, painting, picture or work of art
any item
No Limit
$10,000
No Limit
7.
Collection (stamps, medals, phone cards, collector trading cards or coins)
any one collection
$3,000
$3,000
$1,000
8.
Hearing aids and dentures
any item
No Limit
$3,000
No Limit
9.
10.
Portable electronic equipment
total all items
No Limit
$2,000
$1,000
Parts and accessories of motor vehicle, watercraft, aircraft
total all items
$2,500
$2,500
$1,000
Do you wish to apply for cover above any of these limits?
Yes No If ‘Yes’, please give details below:
Description of item
Valuation number
Value $
$
$
$
$
$
$
$
$
$
$
NOTE: These policies do contain other limits – please refer to the policy wording for full details.
POLICY EXCESS
NZI Echelon and Householders
Standard Excess $250 Plus additional Voluntary Excess (with Premium Discount)
$100 $350 $750 Plus additional Voluntary Excess (with Premium Discount)
$250 $500 $1,000 NZI Essence
Standard Excess $500 OFFICE
USE ONLY
$
SUM INSURED
ECHELON and ESSENCE: What is the total cost of replacing the general contents at today’s prices (excluding specified items listed above)?
$
HOUSEHOLDERS: (a) What is the total insurable value of your contents, excluding specified items $ (b) Do you want to purchase the Special Risks Extension?
No Yes OFFICE
USE ONLY
NSRX
Y
NZI RURAL INSURANCE Application Form NZ705/14 04/13
N
PAGE 19
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
Does the general contents sum insured include any individual painting, picture or work of art that
exceeds $25,000 in value?
Yes No If ‘Yes’, please advise the name of artist, name of work, value and details of most recent valuation: PR I VATE M OTOR
Please tick which type of vehicle you are insuring Car Motor Cycle Types of cover (tick cover required)
Full Caravan Trailer Other Third Party Fire and Theft (Specify) Third Party only Make and model of vehicle: Date of manufacture: Registration number: Market value of vehicle/Sum insured ($) Diesel Fuel Type: Petrol Transmission: Automatic Manual Engine size: Turbo: Yes No (cc)
Rotary: Yes No Yes No Yes No Yes No Yes No 1. Has the original engine been replaced or modified?
If ‘Yes’, give full details.
2. Have the original wheels been replaced? (Other than replacement of tyres)
If ‘Yes’, give full details.
3. Has the bodywork or suspension been modified?
If ‘Yes’, give full details.
4. Has the vehicle been fitted with a stereo system worth more than $1,000?
If ‘Yes’, give full details.
Please tick any of the following which apply to your vehicle
Kitset/Replica Left-hand Drive Sports or performance Classic / Vintage Convertible/Cabriolet Orphan *Fuel Efficient *Hybrid * Note: Only vehicles with an efficiency rating of 5.5 litres per 100km or less and can be identified as such on www.rightcar.co.nz or the
current NZI list of Fuel Efficient vehicles on www.nzi.co.nz qualify.
Does the vehicle have a car security system?
(a)Alarm Immobiliser Yes No If ‘Yes’, complete (a), (b) and (c) below
GPS System (b) Was the system fitted by the manufacturer before the vehicle was sold new in New Zealand?
(c) Advise NZSA Star Rating (for alarm/immobiliser)
1 2 3 Yes 4 No 5 If not rated, give details of system NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 20
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
Where is the vehicle usually parked at night? Garage Driveway/Carport On Roadside Other (Specify)
Will the vehicle be used in connection with any profession, business or occupation?
No Yes If ‘Yes’, give full details DETAILS OF THE OWNER(S) AND DRIVER(S)
Full name
Date
of birth
Sex
(m/f)
Occupation
Phone
number
Driver type
(see below)
Licence type
(see below)
Length of
licence held
1.
Yrs
Mths
2.
Yrs
Mths
3.
Yrs
Mths
4.
Yrs
Mths
Driver Type – Select from: M (main), R (Regular), N (Non driver) Licence Type – Select from 1 (Learner), 2 (Restricted), 3 (Full), 4 (International)
POLICY EXCESS
Standard Excess $300 Plus additional Voluntary Excess (with Premium Discount)
$200 $700 Please note:
`` Drivers under 25 and newly licensed drivers are subject to a standard additional excess.
OFFICE
USE ONLY
POLICYX/S
S
V
$
C
ADDITIONAL INFORMATION
Do you want to apply for NZI Roadside Assist cover? (Full cover only)
Yes No Do you want a Named Drivers Discount?
(Up to 2 of the drivers listed above can be named – both must be aged 25 yrs or older)
Yes No If ‘Yes’, please tick the two drivers chosen.
1 2 3 4 Please note:
`` Any other drivers will be subject to an additional excess.
Do you want to exclude all drivers under the age of 25 years for a premium discount?
Yes No Please note:
`` This extension may not be available if we restrict cover to named drivers as part of any special terms to insure the vehicle.
Do you want to apply for the Low Km option?
Yes No If ‘Yes’, what is the vehicle’s current odometer reading? Please note:
`` This option is available if you are applying for Full cover.
`` If you choose this option, all drivers aged under 25 years will be excluded from cover under this policy.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 21
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
B OAT
Name of craft: Type of craft: Date purchased: Price paid: Built by: Serial no: Craft length: Year built: Craft construction:
GRP GRP (sandwich) GRP (over wood) Financier: Maximum speed: Wood Steel Aluminium Other – state type: If self-built – materials price paid: Estimate labour costs:
Engine make: Engine type:
Number of engines: Petrol Diesel Outboard Inboard Other – state type: Year manufactured:
HP: Stern Leg Shaft Drive Serial no(s): PRECISE LOCATION OF INSURED CRAFT WHEN NOT IN USE
LOCATION 1
Mooring type/storage location: Mooring number: LOCATION 2
Mooring type/storage location: Mooring number: SECURITY
FIRE EXTINGUISHER(S)
Type: Number of: Describe type of trailer anti-theft locking device: Describe security alarm system: LIST OF PROPERTY TO BE INSURED
Amount insured
Hull, fixtures, fittings and machinery (includes outboard motors)
$
Mast, spars, rigging and sails (sailboats only)
$
Boat trailer make Crafts gear (*see definition) plus dinghies, auxiliary outboards etc.
Reg No
$
$
*Crafts gear means the items used with the craft, such as electronic equipment including radio telephones, depth sounders, GPS, chart plotters, marine software, radar, sonar,
audio and TV systems, navigation equipment, tenders, outboard motors, warps, ropes, ground tackle, safety equipment, galley appliances and other items which would normally
be sold with the craft.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 22
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
The following items are equipment to be insured not normally purchased or sold with the insured craft
Consumable ship’s stores
$
Tools
$
Fishing gear
$
Diving gear
$
Wet weather gear
$
Total of all categories – Total amount insured
$
Explanations
`` The maximum amount you will be insured for is to be allocated to the categories shown.
`` Where an amount insured is not shown, cover will not apply to that category.
`` The amounts shown for each category are the insurer’s maximum liability.
`` The crafts gear amount insured must represent its total value.
`` Machinery includes inboard and outboard motors, gearboxes etc.
`` Consumable ship’s stores includes fuel, food, liquor etc.
EXCESS
Policy Excess $ Racing Risk Extension Excess $ USE OF THE BOAT
Will the boat be used for other than private purposes (skippered charter, bare boat charter etc)?
Yes No If ‘Yes’, give details RACING
NOTE: RACING COVER IS AVAILABLE SOLELY ON YACHTS AND TRAILER-SAILERS
The policy conditions exclude cover for loss to sails, masts, spars or rigging while racing unless optional additional racing cover is taken.
Will the boat be used for racing?
Yes No Yes No If ‘Yes’, do you require the Racing Risk extension? (optional additional benefit)
USER EXPERIENCE
Who is the main user of the craft? Give details of their boating experience Give details of any accident with any craft the main user has had in the past three years, whether insured or not
Do they have a Boatmasters certificate or similar?
If ‘Yes’, give details Note: to qualify for discount, the Boatmasters or other relevant certificate must be produced.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 23
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
PLEASE COMPLETE THE FOLLOWING SAFETY REPORT
Please answer each question by ticking either yes or no.
Where a written answer is required please use block letters
1.
Are bilge pumps fitted?
2.
Is a float switch fitted?
3.
a) Are all underwater through hull fittings equipped with gate valves/sea cocks?
Yes
No
b) Are all sea cocks and valves operational?
4.
Is the gas stove installed in accordance with N.Z. S 5428; i.e. is bottle on deck or in cockpit locker vented overboard and are lines of approved
material?
5.
Are fuel tanks externally vented?
6.
If petrol engine, are bilge blower and gas detector installed and operational?
7.
Are spare anchors carried on board?
8.
Is there an alternative means of propulsion (oars, paddles, auxiliary motor)?
9.
Do you carry a set of flares?
10.
Do you hold charts for all the areas in which you operate?
11.
Is there another fire extinguishing system?
12.
Is the engine fitted with an audible pressure/temperature alarm system?
13.
Can you sail a yacht?
14.
Have you studied navigation?
15.
Have you attended any courses on diesel engines?
16.
If on a swing mooring, is it designed for this craft?
17.
Is the mooring subject to a current lease by a controlling authority?
18.
Is the mooring lifted from the water and inspected in accordance with regulations or at least once every two years where none apply?
19.
Are all mooring deficiencies remedied promptly?
Notes
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 24
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
GENERAL QUESTIONS
1. Have you or any other person or entity to be covered by the insurance such as your spouse, de facto partner,
family members, business partners, trustees and/or beneficial owners:
(a) had any insurance declined, cancelled, or been refused renewal, or had any special conditions imposed, Yes No (b) ever been imprisoned for any criminal offence, or
Yes No (c) had any conviction for a criminal offence within the last 7 years?
Yes No (d) had been sued for unpaid debts, or managed a company place in receivership or liquidation?
Yes No Yes No (a) had any motor vehicle accidents, damage or theft in the last 5 years (whether a claim was made or not)?:
Yes No (b) ever been indefinitely disqualified from driving for repeat alcohol or drug related driving offences?
Yes No (c) had any conviction or fine for any other driving offence within the last 5 years?
Yes No including excesses in the last 5 years?
2. Is there any other information likely to affect this insurance?
If you have answered ‘Yes’, to any of the above please give full details below:
3. Have you or anyone who will drive any vehicle you are insuring:
If you have answered ‘Yes’, to any of the above please give full details below:
Date of conviction
Nature of offence
NZI RURAL INSURANCE Application Form NZ705/14 04/13
Amount of money involved
Sentence imposed
PAGE 25
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
4. Does anyone (other than the Insured) have a financial interest in any property, machinery or
motor vehicles? Yes No If ‘Yes’, please give details of Interested Party:
Insured item details
Interested party name
Interested party address
Property
Machinery
Motor Vehicles
PLEASE NOTE: This information is safeguarded by the Privacy Act 1993.
INSURANCE COVER TAKEN/ NOT TAKEN (CHECKLIST)
PROPERTY INSURANCE
Rural Material Damage Taken Not Taken Rural Business Interruption
Taken Not Taken Rural General (Broadform) Liability
Taken Not Taken Rural Statutory Liability
Taken Not Taken Rural Employers Liability
Taken Not Taken COMMERCIAL MOTOR INSURANCETaken Not Taken LIABILITY INSURANCE
OTHER INSURANCE
Income Protection Taken Not Taken Machinery Breakdown
Taken Not Taken Stock Deterioration
Taken Not Taken LivestockTaken Not Taken PERSONAL INSURANCE
HouseTaken Not Taken ContentsTaken Not Taken Motor Vehicle
Taken Not Taken BoatTaken Not Taken NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 26
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
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: 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.
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 27
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
FOR OFFICE USE ONLY – PREMIUM SUMMARY
Company annual premium
Company first premium
Rural Material Damage
Rural Material Damage Earthquake
Rural Business Interruption
Rural Business Interruption Earthquake
Rural General Liability
Rural Statutory Liability
Rural Employer’s Liability
Rural Commercial Motor
Rural Livestock
Total Company Premium
Flexisteps Loading
Government Earthquake
Fire Service Levies
Subtotal
GST
Total
Monthly/Quarterly Premium
FOR OFFICE USE ONLY – UNDERWRITING
FOR OFFICE USE ONLY
Agent no: OFFICE
Client no: USE FOR FLEXISTEPS ONLY
Review date: Abbreviated name: Pay plan: Service codes: Months paid: Premium paid: $ Office: Receipt no:
By: UNDERWRITING ACTION
ANZSIC code: First instalment date: ACCEPTANCE ACTION
Survey on file?
No Yes Serviced by code: Survey required?
No Yes Personal authority?
No Yes RI classification:
No Yes Manager authority?
No Yes Accum. Reg Advice?
No Yes Head office UAA?
No Yes Date A.R. Advised:
No Yes Accepted by: Reinsurance required?
No Yes Date accepted: NZI RURAL INSURANCE Application Form NZ705/14 04/13
Notes: PAGE 28
Rural / I N S U R A N C E A P P L I CAT IO N FO R M
SUM INSURED CALCULATIONS
Difference basis
Net profit and insured standing charges
Turnover
$
Plus closing stock
$
Subtotal
$
Less opening stock
$
Subtotal
$
Deduct uninsured variable working expenses as listed below:
Net profit (before tax)
Plus insured standing charges
(non variable) including all wages
and salaries unless insured separately.
1.
2.
1. Purchases
$
3.
2. Wages
$
4.
3. Power
$
5.
4. Consumable stores
$
6.
5. Cartage
$
7.
6. Packing materials
$
8.
7. Bad debts
$
9.
8. Discount
$
10.
9.
$
11.
$
12.
Subtotal
Plus allowance for trend in the
business anticipated during the
next 12 months
$
Plus allowance for trend in the
business anticipated during the
indemnity period
$
INSURED PROFIT $
$
13.
Subtotal
$
Trend
$
Trend
$
INSURED PROFIT $
NOTES
NZI RURAL INSURANCE Application Form NZ705/14 04/13
PAGE 29