Please list details of previous convictions or infringements for any driving or criminal offence within the last 5 years. (If non state NIL)
I/We declare that the information supplied on this claim form is true in every respect.
I/We consent to the use of my personal information I have provided on this form for the purpose of processing my claim. I understand that if I choose not to provide the required details, this is my choice, however, my claim may not be able to be processed. * I consent to the disclosure of my personal information to other Insurers, an Insurance reference service or as required by law. I consent to also disclosing my personal information to and/or collecting additional information about me, from investigators or legal advisors.
* This consent only applies when a claim is submitted in relation to a policy issued to the individual, not a company or business