OWNER BUILDER INSURANCE –

VOLUNTARY WORKERS APPLICATION

CLIENT INFORMATION

Full Name (S): _________________________________ Business: _________________________________ Address: _________________________________ Phone: _________________________________ Mobile: __________________ Email: __________________________________ Fax: __________________ UNDERWRITING INFORMATION

1. How many Voluntary Workers in total? □ Less than 10 □ More than 10 2. What is the usual number at any one time? □ Less than 10 □ More than 10 3. Occupation? Building Project 4. Estimated Value of the Project? $___________ 5. Have you ever made an insurance claim under any Accident or sickness or travel policy? □ Yes □ No If yes, please provide details: __________________________________________________________________________________________________________________________________________________________________________ DECLARATION

I/We confirm that the answers and statements in this proposal are correct and that no information has been supplied or withheld in breach of the duty of disclosure which is set out above, nor have I/We misrepresented any information supplied to you which could affect your acceptance of this proposal or the terms of the policy. I acknowledge that the Insurer will have no liability whatsoever until it accepts this application by issuing a Policy Schedule/Certificate and that the Insured Person’s duty to disclose any matter material to the Insurers decision whether to issue a Policy and what terms and conditions to offer continues until the Insured has issued the Policy Schedule/Certificate. Signed: _______________________________ Date: ________________________ Print Name: ________________________________________________________________ DUTY OF DISCLOUSURE Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act (1984), to disclose to the insurer every matter you know, or could reasonably be expected to know, is relevant to the insurer’s decision wether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter: - that diminishes however the risk to be undertaken by the insurer - that is of common knowledge, - that your insurer knows or, in the ordinary course of its business, ought to know, - as to which compliance with your duty is waived b y the insurer. Non-disclosure If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from it’s beginning.