Courier Care Application Form

Application Form

IMPORTANT: This Courier Application covers 4 insurance components:
A minimum of 3 out of the 4 insurance components must be taken.
Complete this Courier Application form if you require insurance cover to commence. Contact our office separately if you are seeking a quotation only.

Do you want to include Motor vehicle insurance?
YesNo

Do you want to include Public Liability insurance?
YesNo

Do you want to include Goods in Transit insurance?
YesNo

Do you want to include Personal Accident or Personal Accident & Sickness insurance?
YesNo

Insured Details


Motor Vehicle Application

Use above details

Have you in the past 5 years:

Public Liability Application

Limit of Indemnity = $20,000,000

Marine Transit Application

Limit of any one carry = $200,000

Personal Accident and Sickness Cover

PLEASE TICK THE LEVEL OF COVER THAT YOU REQUIRE

Accident cover is available up to 75 years of age, Sickness cover is only available up to 70 years of age. Any claims paid for accident or sickness will be paid based on 85% of your weekly earnings up to a maximum of the sum insured nominated

C1
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$50,000
$500
$500
C2
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$50,000
$500
NO COVER
C3
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$75,000
$750
$750
C4
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$75,000
$750
NO COVER
C5
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$100,000
$1000
$1000
C6
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$100,000
$1000
NO COVER
C7
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$125,000
$1,250
$1,250
C8
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$125,000
$1,250
NO COVER
C9
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$150,000
$1,500
$1,500
C10
CAPITAL BENEFIT
WEEKLY ACCIDENT
WEEKLY SICKNESS
$150,000
$1,500
NO COVER

Insurance and Medical History


Payment Option *

Bank AccountCredit CardsPremium debited from courier driver's pay (if permitted)

By clicking here, I HEREBY DECLARE AND WARRANT that the answers given are in every respect true and correct and that I have not withheld information within my knowledge likely to affect the decision of the company as to my eligibility for insurance. I hereby agree that this Proposal and Declaration shall be the basis of the contract between the Company's Policy subject to the terms and conditions to be contained therein. I hereby declare that I have read the GSK Insurance Financial Services Guide.
NOTE: I / We give consent to Graham Knight Insurance Brokers to disclose details of my / our Insurance Arrangements to the Courier Company I / We are contracted to. that the answers given are in every respect true and correct and that I have not withheld information within my knowledge likely to affect the decision of the company as to my eligibility for insurance. I hereby agree that this Proposal and Declaration shall be the basis of the contract between the Company's Policy subject to the terms and conditions to be contained therein.


No Cover attaches until we have confirmed acceptance of cover to you in writing.

A minimum of 3 out of the 4 insurance components must be taken.