Courier Care Application Form

Application Form

IMPORTANT: This Courier Application covers 4 insurance components:
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

Duty of Disclosure

Eligible contracts (private motor, strata, home, contents, travel, personal accident/disablement)

If the insurer asks you questions that are relevant to their decision whether to insure you and on what terms, you are required to tell the insurer about anything you know and that a reasonable person in the circumstances would include in answering their questions.

At renewal the insurer may give you a copy of anything you previously told them and ask you to advise them if that information has changed. If they do this, you must tell them about any change or tell them if there is no change. If you don't tell the insurer about a change, the insurer assumes there is no change to this information.

This duty applies until the insurer agrees to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract.

All other contracts

Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect their decision to insure you and on what terms.

You have this duty until they agree to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract. You do not need to tell the insurer anything that:

  • reduces the risk they insure you for;or
  • is common knowledge;or
  • they know or should know as an insurer;or
  • they waive your duty to tell them about.

If you do not tell the insurer something

If you don't tell the insurer something you are required to tell them, they may cancel your insurance contract or reduce the amount theywill pay you if you make a claim, or both. If your failure to tell them is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed.


Payment Option *

Bank AccountCredit Cards

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.

Please note if you wish to proceed with this Courier Care Insurance Pack, you are required to pay a non-refundable initial deposit of $50 which will go towards your initial monthly instalment due on 28th of this month. Once in receipt of the initial deposit of $50, we will email you a Certificate of Placement confirming the cover.

Kindly contact our office to pay the $50 non-refundable deposit on the phone with your Visa or Master card if you need the Certificate of Placement urgently. If we deduct this deposit using your BSB and Account Number this may take up to 3 business days to receive the funds and a Certificate of Placement will be issued then.


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