Freeman Mcmurrick Quotation & Proposal Securus Motor Insurance Page 6
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I/We agree on my own behalf and on behalf of all other insured persons that: the within statements are true. The Duty of Disclosure has
been complied with. The Vehicle described is and shall be maintained in an appropriate condition. When signing the Proposal/Quotation
Form, I/We acknowledge that should some or all of the answers stated in this form NOT be in my/our own handwriting, the answers have
been checked and I/We certify they are correct and that I/We agree to accept a policy subject to the terms, exceptions and conditions
prescribed therein. The vehicle to be insured shall not be driven by any person under 25 years of age. The vehicle to be insured shall not be
driven by any person who to my/our knowledge has been refused any motor insurance or the continuance thereof. The Product Disclosure
Statement (PDS) for this policy may be made available as described in the “Our Product Disclosure Statement’ notice. I/We have read and
agree to the terms of the Privacy Notice.
Applicant’s signature
Title
Dated (DDMMYYYY)
Important notices
1. This Insurance is underwritten by Certain Underwriters at Lloyd’s. The names and percentages of the applicable syndicates are available
upon request to Freeman McMurrick Pty Ltd. You can contact Lloyd’s in Australia at; Lloyd’s Australia Limited, Suite 2, Level 21 Angel
Place, 123 Pitt Street, Sydney NSW 2000, Telephone (02) 9223 1433.
2. Freeman McMurrick acts as an agent of Certain Underwriters at Lloyd’s in arranging and entering into this motor insurance, not the Insured.
3. This quotation is valid only for a period of thirty (30) days and may be withdrawn or varied at any time by us.
4. By submitting the request for quotation you confirm that you have read and agree to the terms of the Privacy Notice sent to you by us.
5. In submitting the information you are acting as agent of the proposed insured(s) and are doing so on their behalf.
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Practice Manager
Brendan Marsh
.au
t 07 3223 7549 f 07 3223 7497
SA, TAS, VIC & WA
ACT, NSW, NT & QLD
Canute Jacob
Paul Behm
.au
.au
t 03 9211 3706 f 03 9211 3740
t 02 9253 7219 f 02 9253 7001
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