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Accident and Illness Proposal

Details of the Insured
Personal Details
Benefits Required
Insured Person’s Acknowledgement
Please give details including description of injury or illness, duration (dates), the cause, nature of treatment and results, current condition, name and addresses of doctors and hospitals consulted. If there is in sufficient space please attach details.
Hazardous Activities

Do you currently, or do you intend to engage in any hazardous pursuit or pastime, including but not limited to football of any code, boxing, rodeo activities, wrestling, martial arts, racing of any kind (other than on foot), motorsports, polo, water skiing, scuba diving or underwater activities, parachuting, parasailing, hang gliding, or other aerial activities, ski jumping, snow or ice sports, grass skiing, mountaineering, bungee jumping, abseiling, caving, shooting or training for or participating in professional sport of any kind. If “YES” please provide details.



Lloyd’s and its agents are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Private Sector) Act 2000 (The Act). This sets out the basic standards relating to the collection, use, disclosure and handling of personal information. “Personal Information” is essentially information or an option about a living individual whose identity is apparent or can reasonably be ascertained from the information or opinion. Information will be obtained from individuals directly where possible. Sometimes it may be collected indirectly (e.g. from your representatives). Only information necessary for the arrangement and administration of Lloyd’s, its agents and their representatives will be collected. This includes information necessary to accept the risk, to assess a claim, to determine competitive and appropriate premiums, etc. Lloyd’s and its agents disclose personal information to third parties who they believe are necessary to assist them in doing the above. These parties will only use the information for the purposes we provided it to them (or if required by law). When you give Lloyd’s and its agents personal information about other individuals, we rely on you to have made or make them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it. If it is sensitive information we rely on you to have obtained their consent on these matters. If you have not done or will not do either of these things, you must tell us before you provide the relevant information. You are entitled to access your information if you wish and request correction if required. You may also opt out of receiving materials sent by Lloyd’s by contacting Lloyd’s General Representative by telephone on: (02) 92231433.


The Insurer for your policy is Lloyd’s of London. Tailored Underwriting is a division of Cerberos Brokers Pty Ltd ABN 61 106 769 886, AFSL 260668. Tailored Underwriting arrange policies for and on behalf of certain Underwriters at Lloyd’s and acts under a binding authority given to it by the insurer to administer and issue policies, alterations and renewals. In all aspects of this policy Tailored Underwriting acts on behalf of the insurer and not for you. Tailored Underwriting are not the insurer for this contract and they are not liable for any loss or claim. The Underwriters are clearly shown on the Schedule.


The law requires You to tell Us everything You know (or could reasonably be expected to know in the circumstances) which is relevant to Our decision to insure You and the terms on which We insure You. This duty applies before You enter into a contract with Us, that is, before We accept Your application and also before each time You alter or renew the Policy. Each person listed as the Insured Person has the same duty.

Penalty for Non-disclosure -If You or the Insured Person do not tell Us everything that is relevant, We may reduce or refuse to pay a Claim, cancel Your or the Insured Person’s Policy, or invalidate the Policy from its beginning and not be bound by it if You or the Insured Person act fraudulently. You or the Insured Person do not need to tell Us anything which reduces the risk, is common knowledge, We already know, or ought to know in the ordinary course of Our business, or We indicate that We do not want to know. If You or the Insured Person are not sure that something is relevant, it is best to disclose it. Also, You and the Insured Person must notify Us of any changes which affect Your or the Insured Person’s Policy.

What you must tell us - When answering our questions, you must be honest and you have a duty under law to tell us anything known to you, and which a reasonable person in the circumstances, would include in answer to the question. We will use the answers in deciding whether to insure you and anyone else to be insured under the policy, and on what terms.

Who needs to tell us - It is important that you understand you are answering our questions in this way for yourself and anyone else whom you want to be covered by the policy. If you do not tell us - If you do not answer our questions in this way, we may reduce or refuse to pay a claim, or cancel the policy in accordance with the Insurance Contracts Act 1984. If you answer our questions fraudulently, we may refuse to pay a claim and treat the policy as never having existed.


 I Hereby declare and warrant that the answers given above are in every respect true and correct, and that I have not withheld any information within my knowledge likely to affect the decision of the insurer as to my eligibility for insurance for pre-existing conditions. The declaration shall be the basis of the contract in consideration of giving disclosed pre-existing conditions between the insurer and myself, and I agree to accept the insurer’s policy subject to the terms and conditions to be contained therein. I further authorise the insurer to consult my doctor regarding any condition declared on this declaration and authorise my doctor to release any information relevant to same.

Financial Services Guide and Privacy Statement.