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barracks contents insurance proposal

Underwritten by Lumley General Insurance (N.Z.) Limited,Head Office, Lumley House, 7 City Road, PO Box 2426, Auckland, New Zealand, Tel 09 308 1100, Fax 09 308 1114

Insured detailsInsureds full name: Date of birth: / /

Direct debit a/c no: NZDF service no:

Situation/barrack unit:

Postal address (if different from above): Daytime phone number:

Period of insurance: From: / / To: / / and subject to renewal: Fortnightly Monthly thereafter

Contents

Sum insured: $5000 $10,000 $20,000 $30,000

Excess: $100 on base and $250 off base.

Contents Policy limits

You cannot claim more than:

$1000 for any item of jewellery or watch, fur, camera or item of photographic equipment, bicycle or item of sporting or recreational equipment,portable phone.

$1000 in total for stamps, medals, coins, telephone cards, collector cards or firearms, unless it is shown above with a specified sum insured.

These specified sums insured are additional to the contents sum insured.

Any specified item of jewellery or watch is limited to $1000 until we receive (prior to loss) a valuation confirming its sum insured.

Note: the policy does contain other limits,please refer to the policy wording for full details.

Specified items

Description: Sum insured: $Description: Sum insured: $

Description: Sum insured: $

General questions

1 Have You or any other person to be covered under this policy or any person who may benefit from this insurance:

(a) In the past 5 years experienced any loss (whether or not a claim was made) for contents insurance? Yes No

(b) Ever experienced any loss of $5,000 or more to any property? Yes No

(c) Ever withdrawn a claim? Yes No

(d) Ever had insurance voided, refused, cancelled, renewal not offered,special conditions imposed or a claim refused? Yes No

2 Is the property used for anything other than private purposes? Yes No3 Is there any further information that may affect the acceptance of this insurance? (For example bankruptcy or insolvency; flood;

hazardous processes;or any circumstances giving greater than normal risk of loss. Note: this is not an exhaustive list.) Yes No

IfYes, to any of the above please give details:

4 Previous insurer: From: / / To : / /

New Zealand Defence Force

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Important information

Our maximum liability

The most we will pay for any loss or series of losses arising from one event is the sum insured shown in the schedule plus any Extensions which are

stated in the policy to be additional.

The Legal Liability Extension is additional to the above.

Declaration

To be completed by the insured(s) shown and also on behalf of their spouse, family members and any other person covered by these insurances.

I/We declare that:1 All information contained in this proposal and on any attachment is complete and correct;

2 I/We have disclosed all information relevant to the acceptance of this proposal;

3 I/We agree that this proposal shall be the basis of the contract between me/us and the company and I/we am/are willing to accept the terms,

conditions and exclusions of these insurances;

4 The sums insured represent the full value of the property insured;

5 I/We understand that this proposal requests personal information about me/us which is held by Lumley General Insurance (N.Z.) Limited to

evaluate my/our application for insurance. Failure to provide the information sought may result in my/our application being declined or my/our

insurance being void from the beginning;

6 By signing this form I/we authorise Lumley General Insurance (N.Z.) Limited to:

a) check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access;

b) disclose personal information to other members of the insurance industry and/or parties who have a financial interest in the subject matter

of this insurance;

c) obtain personal information held by any other party regarding my/our existing and previous insurances;

7 I/We understand that there are rights of access to and correction of information held by Lumley General Insurance (N.Z.) Limited and on the

Insurance Claims Register;

8 I/We understand that no insurance is in force until this proposal has been accepted by the company.

Signature of Insured(s): Date: / /

Premium Contents Specified Total

Company $ $ $ Policy no:

EQC $ $ $ Customer no:

FSL $ $ $ Branch:

GST $ $ $ Agency:

Total $ $ $ Authorisation no:

For office use only:

form CB00? 06/05