Insurance Proposal Form
This is a fully online application form so you will need to include an email address and telephone number. You will also need to have read, understood and agree to the declarations and notice to the proposed insured
before submitting your acceptance. Please do not hesitate to contact Gary Crompton on 03 9211 3253 should you have any questions.
1. By clicking 'submit' I acknowledge that I have read, understood and agreed to the Notice to the Proposed Insured provided on this application form.
2. I acknowledge that if this application is accepted, the insurance cover will be subject to the terms and conditions as set out in the Policy Schedule and Policy Wording.
3. I declare that the information contained in this application form is true and correct and that I have not suppressed nor misstated any facts.
4. I declare that if I am required to hold registration with a registration board (whether it be a state, territory or national board in which I practice), that I will maintain registration for the term of this insurance policy.
5. I acknowledge that Aon values the privacy of personal information and is bound by the Privacy Act 1988 (Clth) when they collect, use, disclose or handle personal information.
6. I acknowledge that Aon collects personal information to offer, provide, manage and administer the services they provide in accordance with Aon’s Privacy Statement. I consent to the use of my personal information for the purposes shown in the Aon’s Privacy Statement, and the disclosure of my personal information to, and obtaining personal information from, other parties, including those shown in the Privacy Statement, for any of these purposes.
7. If I have disclosed personal or sensitive information about any other person, I confirm that I have obtained consent from that person to disclose to you their personal or sensitive information and have made them aware that you will or may provide their information to other third parties, including the insurer for any of these purposes, and for the purposes which we or the third parties may use the information for, including those outlined in the Privacy Statement. If I have not obtained consent and authorisation from any other person to disclose their personal or sensitive information to you, I will inform you before providing relevant information.
|DETAILS OF INSURED|
|Current declared values:|
|OPTIONAL PRODUCTS/SERVICES COVERAGE|
|If you have ticked any of the above boxes, your Aon representative, Gary Crompton, will be in contact with you to discuss your requirements.:|
By submitting this form, you acknowledge that you have read the Aon Privacy Notice and agree that we can handle any personal information you have provided to us in the manner set out above.:
- Aon is committed to protecting your personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). We collect, use and disclose personal information to offer, promote, provide, manage and administer the many financial services and products we and our group of companies are involved in as set out in the Aon Privacy Notice.
- If you are disclosing personal or sensitive information about any other person to Aon, you confirm that you have obtained the consent of that person to disclose to Aon their personal or sensitive information and you have made them aware that Aon will or may disclose their information to third parties that are reasonably necessary to assist in the provision of the relevant services or products. If you have not obtained consent from this other person to disclose their personal or sensitive information to Aon, you will inform us before providing the relevant information to us.