Name of insured* First Last ABN* Trading Name* Are you a member of the Australian Photographic Society?* Yes No Name of Organisation Membership No. Postal Address* Street Address Email* Telephone no.* Period of Insurance from* DD dash MM dash YYYY Address of premises where equipment is normally kept* Street Address Has the applicant or any other person to whom this insurance will apply:suffered any loss during the past five (5) years from any events you wish to insure?* Yes No Please list*Date of LossDescription of LossAmount ($) had any insurance declined, cancelled, proposal/application declined, renewal refused, claim declined, special conditions or excesses imposed by an insurer?* Yes No ever been declared bankrupt, insolvent or had a liquidator appointed?* Yes No ever been convicted of a criminal offence?* Yes No been charged or convicted of any offence involving dishonesty of any kind??* Yes No If any questions have been answered “YES”, please provide details*Camera & Accessory EquipmentDescriptionSerial No.Sum Insured Computer EquipmentYear of PurchaseMake and ModelSerial NumberSum Insured How did you hear about us?*Select oneGoogleAdsNewsletterWord of mouthOtherNotice To Insured. Pursuant to the provisions of the Insurance Contracts Act 1984 DISCLOSURE OF RELEVENT FACTS a) Your Duty of Disclosure 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 be expected to know, that is relevant to the Insurer’s decision whether to accept the risk of 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 any matter: that diminishes the risk to be undertaken by the Insurer that is of common knowledge that your Insurer knows, or in the ordinary course of our business ought to know as to which compliance with your duty is waived by the Insurer. Your duty of disclosure extends to not only answering the questions on the Proposal Form but, to all matters which are relevant to the risk, and you must notify the Insurer of changes in the risk between the time of your answering the questions on the Proposal Form and the date the Contract of Insurance is entered into. b) Non - disclosure If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract. If you non-disclosure is fraudulent, the Insurer may also have the option of voiding the contract from its beginning. DECLARATION I/We desire to affect with the Company Insurance under the terms of the Policy used for this class of business and I/We warrant that the statements in this proposal and any other information provided in connection with the proposal are correct and complete and I/We agree that they shall form the basis of the contractSignature*Date* DD dash MM dash YYYY CAPTCHA Δ