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Cover Note Request Form

Cover Note Request Form

Thank you for selecting National Transport Insurance.

To ensure that your client’s interests are fully protected we require the following information.

You acknowledge that completion and submission of this document represents that you act on behalf of your client.

You acknowledge that you have provided your client with advice in relation to the DUTY OF DISCLOSURE, AVERAGE/UNDER INSURANCE, THIRD PARTY INTERESTS and SUBROGATION clauses.

You acknowledge that if requested by National Transport Insurance, your client agrees to obtain from the appropriate Commissioner of Motor Transport within 14 days of receiving notice thereof, a complete and up to date record of offences in respect of which your client has been reported and/or convicted.

You acknowledge that all particulars and statements contained in the original quote request are those of your client, and are true and correct, and that together with this declaration, they shall form the basis of the contract between your client and National Transport Insurance and be incorporated therein.

You acknowledge that neither your client nor yourself have withheld any information to our questions that is likely to affect our cover, in that we may reduce or refuse to pay a claim on this Cover Note.

You acknowledge that if your client answered our questions fraudulently, we may refuse to pay a claim and treat the cover as not have been effected.

  Please indicate your acceptance by ticking: I accept the terms of this declaration    
Cover Note Details
  * Quotation Number:    
  * Cover Required From: / /
  Note: Cover will commence at 4pm local time on the above date unless specified by NTI Express.
Proposer Details
  * Name of the Proposer:
  ABN Number:
  * Trading Name:
  * Phone Number:   Mobile Phone Number:  
  * Street No & Name:
  * Suburb:
  * Postcode:
  Email Address:
Vehicle Details
Number of vehicles to be insured.(Please place in same order as per Quote form):
Vehicle Operations
* Are the vehicle(s) owned or registered by anyone other than this insured?
* Is the vehicle in a safe, roadworthy, undamaged condition?
* Is any vehicle lent out, leased out, or control assigned to any other party (i.e. Dry Hired)?
 
Trailers In Control
* If you have been quoted for Trailer In Control, do you require cover to be placed on the quoted Trailer In Control items:
No Claim Bonus
* Are you entitled to a No Claim Bonus?
Liability Cover
* If NTI Express has quoted you for Liability Cover, do you require Liability Cover?
Marine Cargo Cover
* If NTI Express has quoted you for Marine Cargo Cover, do you require Marine Cargo Cover?
Business Interruption Cover
* If NTI Express has quoted you for Business Interruption Cover, do you require Business Interruption Cover?
Submit Cover
* Intermediary Email Address:
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