Limousine Insurance Proposal Form, Lumley

1. Drivers
a) Please give details below of all persons who usually drive your vehicle(s)
(b) Have you or any of the above named drivers in the last five years:
i) had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? Yes No
ii) had any driving offences or traffic infringements (other than parking) or a drivers licence cancelled or suspended? Yes No
iii) had any insurance declined or cancelled, been refused renewal of any insurance, or had special terms, conditions or excesses imposed? Yes No
c) Do any of the above named drivers suffer from any physical or mental disability or any mental condition which could affect their driving performance? Yes No
Complete section below if you have answered YES to any of the above questions.
No Claim Bonus
a) What is your entitlement to a No Claim Bonus discount?
b) Have you been insured under a Comprehensive Motor Vehicle policy in the last three years? Yes No
If yes, please indicate names of insurers and the dates involved.
PLEASE ATTACH CURRENT DOCUMENTATION IN CONFIRMATION OF THE NO CLAIM BONUS
Insurance History
Give the following details of Motor Insurance held by you during the past three years:
Declaration
I/We declare that the answers given herein are in every respect true and correct and that I/We have not withheld any information likely to affect the acceptance of this
Proposal and that I/We have read and understood the Proposal and Policy Conditions. If insufficient space is provided on this Proposal in respect of any questions contained
on the Proposal, please attach a sheet of paper containing the additional information, noting the relevant heading and sign and date such attachment.
Owner or Years Class of % of
Full Name Age Date of Birth Occupation Employee Licenced Licence Vehicle Use
Details of Accident, Amount of Details of Physical
Name Loss, Convictions, etc. Date Loss/Fine Insurance Company or Mental Disability
% Years
Year Insurer Type of Cover Excess No. of Claims Total Claims Details of Claims
Signature Date: / /
LG 420A 06/09
commercial / business vehicle proposal
commercial / business vehicle
proposal
LGI 420A.qxd 22/6/09 11:31 AM Page 2

2. Important Notice
(Please read before completing this Proposal)
you, your refers to the person(s) completing this Proposal.
we, us refers to Wesfarmers General Insurance Limited ABN 24 000 036 279, trading as Lumley Insurance.
Your Duty of Disclosure
By law, if you do not tell us everything you know, or should know, is relevant to our decisions about this insurance, we may:
(a) reduce, or refuse to pay a claim
(b) cancel the Policy
(c) avoid the Policy from its commencement if your omission was deliberate.
Lumley Insurance Repair Network
Lumley Insurance has established an elite preferred repairer network system. Members of the Lumley Insurance Repair
Network meet our stringent acceptance criteria which require the highest standards of repair and service.
When you use a repairer from the Lumley Insurance Repairer Network system you do not need to shop around for quotes
and we guarantee:
(a) the quality of parts and workmanship involved in the repair, and
(b) that the structural integrity of your vehicle has been maintained.
You may choose your own repairer, but if you do, we will not provide this guarantee.
Excess
You will have to contribute the excess stated on your Policy Schedule and one of the following additional amounts if, at
the time of the accident, the person driving the insured vehicle was:
(a) under 21 years of age - $1,000
(b) aged between 21 & 25 years of age (inclusive) - $500.
Goods & Services Tax
To insure you do not incur any unnecessary GST liabilities on claims settlements, please ensure your Australian Business
Number (ABN) and tax status are entered in the space provided on this Proposal.
Privacy
Lumley General respects your privacy and compiles with the Privacy Act and the National Privacy Principals.
A copy of our Privacy Policy is available at any of our offices or at our website - www.lumley.com.au
Confirming Transactions
You may contact us or your adviser, in writing (which is a requirement if you are advising cancellation) or by phone, to
confirm any transaction under the Policy. Any transaction will be documented as quickly as possible.
Please contact your nearest Lumley Insurance office for further information.
Wesfarmers General Insurance Limited A.B.N. 24 000 036 279
Adelaide 465 Pulteney Street,SA 5000 Tel (08) 8228 1700 Fax (08) 8228 1777 • Brisbane Level 2,99 Melbourne Street,South Brisbane QLD 4101.GPO Box 524,Brisbane
QLD 4001 Tel (07) 3307 4800 Fax (07) 3307 4899 • Canberra Level 4,10 Rudd Street,Canberra ACT 2601 Tel (02) 6279 0333 Fax (02) 6279 0330 • Darwin Level 2,Beagle
House,38 Mitchell Street, Darwin NT 0800 Tel (08) 8946 4600 Fax:(08) 8946 4666 • Launceston 27 Paterson Street,TAS 7250 Tel (03) 6345 4700 Fax (03) 6345 4711 •
Melbourne Level 3,99 King Street, VIC 3000 Tel (03) 8627 4333 Fax (03) 8627 4312 • Newcastle 50 Glebe Road,The Junction,NSW 2291Tel (02) 4925 7500 Fax (02) 4940
0295 • Perth 50 St. George’s Terrace, WA 6000 Tel (08) 9220 8222 Fax (08) 9220 8251 • Sydney Lumley House, Level 9, 309 Kent St, NSW 2000 Tel (02) 9248 1111 Fax
(02) 9248 1122 • Townsville Level 5, Northtown Tower, Flinders Mall,Townsville QLD 4810 Tel (07) 4722 6000 Fax (07) 4728 4398
Wesfarmers General Insurance Limited ABN 24 000 036 279
commercial / business vehicle proposal
Type of Cover
Period of Insurance
b) Has any vehicle been modified from the manufacturers specification so that its performance is altered? If yes, give details. Yes No
c) Has any vehicle been modified to incorporate special equipment such as a built in fridge, freezer unit, or other specific changes? If yes, give details. Yes No
d) Are any vehicles goods carrying? If yes, give details of goods carried. Yes No
e) Will any vehicle carry petrol or diesel oil in bulk, flammable gases, volatile chemicals, acids or other dangerous goods? If yes, give details. Yes No
f) What is the situation of your depot or home base?
g) Indicate radius of travel from your home base Km
The Proposer
Office use only
Full Name of Proposer:
A.B.N:
Tax Status: % entitlement to Input Tax Credits
Postal Address:
Proposer’s Occupation or Business:
Telephone Private: Telephone Business:
Name and Address of Finance Company:
Type of Payment: Hire Purchase Leasing Agreement Mortgage/Bill of Sale Chattel Mortgage Other
a) Give details including values of standard or non-standard equipment such as stereo systems & special tool kits for which you require cover.
Broker/Agent:
Cover Note No:
Excess:
Replacing Policy No:
$ c
From: To: at 4.00pm Local Standard Time
Comprehensive Third Party Property Damage Only
Year Make and Model Body Type Registration Number Carry Capacity
(i)
(ii)
(iii)
Engine Number Date Purchased Purchase Price Current Market Value Financed
(i) Yes No
(ii) Yes No
(iii) Yes No
Premium
Fire Service Levy
GST
Stamp Duty
Total Payable
Motor Vehicle(s) If insufficient space, attach list
LGI 420A.qxd 22/6/09 11:31 AM Page 4

3. Important Notice
(Please read before completing this Proposal)
you, your refers to the person(s) completing this Proposal.
we, us refers to Wesfarmers General Insurance Limited ABN 24 000 036 279, trading as Lumley Insurance.
Your Duty of Disclosure
By law, if you do not tell us everything you know, or should know, is relevant to our decisions about this insurance, we may:
(a) reduce, or refuse to pay a claim
(b) cancel the Policy
(c) avoid the Policy from its commencement if your omission was deliberate.
Lumley Insurance Repair Network
Lumley Insurance has established an elite preferred repairer network system. Members of the Lumley Insurance Repair
Network meet our stringent acceptance criteria which require the highest standards of repair and service.
When you use a repairer from the Lumley Insurance Repairer Network system you do not need to shop around for quotes
and we guarantee:
(a) the quality of parts and workmanship involved in the repair, and
(b) that the structural integrity of your vehicle has been maintained.
You may choose your own repairer, but if you do, we will not provide this guarantee.
Excess
You will have to contribute the excess stated on your Policy Schedule and one of the following additional amounts if, at
the time of the accident, the person driving the insured vehicle was:
(a) under 21 years of age - $1,000
(b) aged between 21 & 25 years of age (inclusive) - $500.
Goods & Services Tax
To insure you do not incur any unnecessary GST liabilities on claims settlements, please ensure your Australian Business
Number (ABN) and tax status are entered in the space provided on this Proposal.
Privacy
Lumley General respects your privacy and compiles with the Privacy Act and the National Privacy Principals.
A copy of our Privacy Policy is available at any of our offices or at our website - www.lumley.com.au
Confirming Transactions
You may contact us or your adviser, in writing (which is a requirement if you are advising cancellation) or by phone, to
confirm any transaction under the Policy. Any transaction will be documented as quickly as possible.
Please contact your nearest Lumley Insurance office for further information.
Wesfarmers General Insurance Limited A.B.N. 24 000 036 279
Adelaide 465 Pulteney Street,SA 5000 Tel (08) 8228 1700 Fax (08) 8228 1777 • Brisbane Level 2,99 Melbourne Street,South Brisbane QLD 4101.GPO Box 524,Brisbane
QLD 4001 Tel (07) 3307 4800 Fax (07) 3307 4899 • Canberra Level 4,10 Rudd Street,Canberra ACT 2601 Tel (02) 6279 0333 Fax (02) 6279 0330 • Darwin Level 2,Beagle
House,38 Mitchell Street, Darwin NT 0800 Tel (08) 8946 4600 Fax:(08) 8946 4666 • Launceston 27 Paterson Street,TAS 7250 Tel (03) 6345 4700 Fax (03) 6345 4711 •
Melbourne Level 3,99 King Street, VIC 3000 Tel (03) 8627 4333 Fax (03) 8627 4312 • Newcastle 50 Glebe Road,The Junction,NSW 2291Tel (02) 4925 7500 Fax (02) 4940
0295 • Perth 50 St. George’s Terrace, WA 6000 Tel (08) 9220 8222 Fax (08) 9220 8251 • Sydney Lumley House, Level 9, 309 Kent St, NSW 2000 Tel (02) 9248 1111 Fax
(02) 9248 1122 • Townsville Level 5, Northtown Tower, Flinders Mall,Townsville QLD 4810 Tel (07) 4722 6000 Fax (07) 4728 4398
Wesfarmers General Insurance Limited ABN 24 000 036 279
commercial / business vehicle proposal
Type of Cover
Period of Insurance
b) Has any vehicle been modified from the manufacturers specification so that its performance is altered? If yes, give details. Yes No
c) Has any vehicle been modified to incorporate special equipment such as a built in fridge, freezer unit, or other specific changes? If yes, give details. Yes No
d) Are any vehicles goods carrying? If yes, give details of goods carried. Yes No
e) Will any vehicle carry petrol or diesel oil in bulk, flammable gases, volatile chemicals, acids or other dangerous goods? If yes, give details. Yes No
f) What is the situation of your depot or home base?
g) Indicate radius of travel from your home base Km
The Proposer
Office use only
Full Name of Proposer:
A.B.N:
Tax Status: % entitlement to Input Tax Credits
Postal Address:
Proposer’s Occupation or Business:
Telephone Private: Telephone Business:
Name and Address of Finance Company:
Type of Payment: Hire Purchase Leasing Agreement Mortgage/Bill of Sale Chattel Mortgage Other
a) Give details including values of standard or non-standard equipment such as stereo systems & special tool kits for which you require cover.
Broker/Agent:
Cover Note No:
Excess:
Replacing Policy No:
$ c
From: To: at 4.00pm Local Standard Time
Comprehensive Third Party Property Damage Only
Year Make and Model Body Type Registration Number Carry Capacity
(i)
(ii)
(iii)
Engine Number Date Purchased Purchase Price Current Market Value Financed
(i) Yes No
(ii) Yes No
(iii) Yes No
Premium
Fire Service Levy
GST
Stamp Duty
Total Payable
Motor Vehicle(s) If insufficient space, attach list
LGI 420A.qxd 22/6/09 11:31 AM Page 4

4. Drivers
a) Please give details below of all persons who usually drive your vehicle(s)
(b) Have you or any of the above named drivers in the last five years:
i) had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? Yes No
ii) had any driving offences or traffic infringements (other than parking) or a drivers licence cancelled or suspended? Yes No
iii) had any insurance declined or cancelled, been refused renewal of any insurance, or had special terms, conditions or excesses imposed? Yes No
c) Do any of the above named drivers suffer from any physical or mental disability or any mental condition which could affect their driving performance? Yes No
Complete section below if you have answered YES to any of the above questions.
No Claim Bonus
a) What is your entitlement to a No Claim Bonus discount?
b) Have you been insured under a Comprehensive Motor Vehicle policy in the last three years? Yes No
If yes, please indicate names of insurers and the dates involved.
PLEASE ATTACH CURRENT DOCUMENTATION IN CONFIRMATION OF THE NO CLAIM BONUS
Insurance History
Give the following details of Motor Insurance held by you during the past three years:
Declaration
I/We declare that the answers given herein are in every respect true and correct and that I/We have not withheld any information likely to affect the acceptance of this
Proposal and that I/We have read and understood the Proposal and Policy Conditions. If insufficient space is provided on this Proposal in respect of any questions contained
on the Proposal, please attach a sheet of paper containing the additional information, noting the relevant heading and sign and date such attachment.
Owner or Years Class of % of
Full Name Age Date of Birth Occupation Employee Licenced Licence Vehicle Use
Details of Accident, Amount of Details of Physical
Name Loss, Convictions, etc. Date Loss/Fine Insurance Company or Mental Disability
% Years
Year Insurer Type of Cover Excess No. of Claims Total Claims Details of Claims
Signature Date: / /
LG 420A 06/09
commercial / business vehicle proposal
commercial / business vehicle
proposal
LGI 420A.qxd 22/6/09 11:31 AM Page 2