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Application Form

(Caravans, Off-Road Caravans, Camper Trailers and Motorhome Insurance)
MUST BE COMPLETED AND SIGNED BY THE INSURED, PLEASE COMPLETE ALL SECTIONS IN BLOCK LETTERS

PERSONAL DETAILS (INSURED)

Driver's Licence*
Vehicle Finance*

LEISURE VEHICLE
DETAILS

EXTRA’S

INCREASED CONTENTS

“Contents” are not available for ECONO Plans

CARA-SURE PRODUCTS
(CHOOSE ONLY ONE)

Cara-Sure Caravans and Motorhomes

Cara-Sure Off-Road Campers

Cara-Sure Pensioner 55

Top-up Cover is automatically included in all CaraSure policies

BANK DEBIT ORDER

Debit Order Deduction Date*

INTERMEDIARY

DECLARATION

PREMIUM PAYMENT DECLARATION

If the policy payment is not accepted, it will not be due to any deliberate action to stop payment of the Debit Order myself, In the event that the premium is rejected by the Bank, I will accept full responsibility for any claim amount, which I may have received or which be paid by the insurer on my behalf as a result of this claim being processed

GENERAL DECLARATION

I/We the insured, understand, agree and, where applicable declare that:
  1. The policy may change from time to time by the insurer by giving 30 days’ notice.
  2. If the above particulars and declaration is not correct, the insurer shall have the right to cancel my policy.
  3. I/We further declare that I/We have read and completed, whether in my/our handwriting or not, the abovementioned declaration and acknowledgement the contents thereof. I/We furthermore hae signed the declaration of my/our own free will and I/We agree it as binding.
  4. This policy is restricted to event occurring while the Leisure Vehicle (mentioned above) is being used for PRIVATE, SOCIAL and PLEASURE purposes ONLY.
  5. This policy does not afford cover whilst the Leisure Vehicle (Caravan, Off-Road Caravan, Camper Trailer or Motorhome) is under construction.
  6. This policy does not afford cover if the Leisure Vehicle is at a Dealer for the purpose of being sold or Rented to any other person/s.
  7. The proposal and declaration and any other information supplied to the Insurer by or on behalf of the insured named in the schedule are the basis of this contract and are to be considered as incorporated herein.
  8. I/We hereby declare that I/We have not withheld any material fact/s and I accept this Application and Declaration to form the basis of the contract between myself and Compass Insurance Company Ltd.
  9. On my own behalf and on behalf of any person I herein represent, I hereby waive any right to any privacy in any insurance information provided by me or on my behalf in respect of any insurance policy or claim made or lodged by me. I also consent to such information being disclosed to any other insurance company or it’s agents.
  10. I waive any rights of privacy and consent to the disclosure of any information to any insurance company or insurance claim concerning me.
  11. I acknowledge that the information provided by me may be verified against other legitimate sources and databases.

PLEASE ANSWER THE FOLLOWING QUESTIONS

Has any Insurer refused any proposal, cancelled any policy or refused to renew any policy or imposed special conditions?*
Are you currently insured?*
I hereby authorise Compass Insurance Company Limited to draw on my account in any manner agreed on, between Compass and their collection agent the premium as stated above.