I hereby declare the statement and particulars I make on the following page to be true and correct and I make
this declaration on the basis that I have delegation of power to sign for and behalf of the insured.
Please complete the below fields, providing as much information as possible.
This will assist the insurer in processing your claim.
If an assessor is appointed, access to the premises may be required.
Please list the name and contact details of the relevant person who can facilitate access.
Before you enter into a contract of general insurance with an insurer, you must disclose to the Insurer every matter that you know, or could reasonably be expected
to know, that is relevant to the insurer’s decision whether to accept the risk of the insurance, and if so on what terms. You must provide accurate information and
not misrepresent the nature of the risk to be insured. The duty also applies also when you seek to renew, extend, alter or reinstate a policy. It applies up to the time the policy is entered into, renewed, altered or reinstated. Your duty, however, does not require you to disclose matters: that diminish the risk to be undertaken by the insurer, that are of common knowledge, that your Insurer knows or ought to know in the ordinary course of their business, as to which compliance with your
duty is waived by the insurer. If you do not comply with your duty of disclosure, the insurer may be entitled to reduce their liability under the contract in respect
of a claim and/or cancel the contract. If your non-disclosure is fraudulent, the Insurer may decline the claim and may avoid the contract from its beginning.
By submitting this form, you confirm that as Owner/Property Manager (please indicate below), you are authorised to make all required
statements and disclosures required to be made to Chubb pursuant to the Insurance Contracts Act 1984 on the Insured’s behalf and that Chubb may rely upon those statements and disclosures for the purpose of determining whether it wishes to provide the requested insurance cover. Furthermore, you are authorised to execute and confirm the disclosures and representations made in this Application Form are correct. If required by Chubb, you will provide such documentation, including written confirmation of my authority to provide this declaration, as Chubb may require to determine if it wishes to provide the requested insurance cover.
You also certify that: