nZi RuRal insuRance application FoRM · RuRal application nZi, a business division of iaG ew Zealand limited Ru Ral insu ance application Form Z705/10 02/10 PAGE 1 nZi RuRal insuRance

RuRal application

PAGE 1nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10

nZi RuRal insuRance application FoRM

DEtailS oF applicant(S)

applicant 1

First name: Surname:

occupation: Date of birth:

applicant 2

First name: Surname:

occupation: Date of birth:

pOstal aDDRess

number/Street:

Suburb: town/city:

cOntacts

telephone: Mobile: Email:

covers already with nZi none House contents car Boat Business

period of insurance From to at 4pm

Farm location (a)

Farm location (b)

any non farm activities? YES no

if ‘Yes’, please supply details

Farm supply number (for dairy)

type of farming: Dairy (108) Horticulture (120/126) pig (113) Sheep (114) lifestyle (115) crop (392)

Deer (109) poultry (102) Beef (107) Horse (100)

paYMEnt optionS

How do you wish to pay? annually Quarterly* Monthly* *Please complete an NZI Direct Debit Authority form.

YouR DutY oF DiScloSuRE

You must tell us all information you know (or could reasonably be expected to know) which would influence the judgement of a prudent underwriter whether or not to accept your application, and if it is accepted, on what terms and at what cost.

examples of information you may need to disclose include:

• anythingthatincreasestheriskofaninsuranceclaim;• anycriminalconvictionsinlast7yearsorwhereimprisoned;• ifanotherinsurerhascancelledorrefusedtorenewinsurance,orhasimposedspecialterms;

• anyinsuranceclaimyouhavemadeinthepast.

examples of information you do not need to disclose include:

• anythingthatreducestheriskofaninsuranceclaim;• anythingwesayyoudonotneedtotellusabout;• anythingthatiscommonknowledge;• anythingyouhavealreadytoldus,orthatweshouldbe

expected to know in the ordinary course of our business.

these examples are a guide only. if you are not sure whether you need to disclose a particular piece of information, please ask.

WHen in DOuBt – DisclOse. all inFORMatiOn Will Be tReateD cOnFiDentiallY.

agent’s name: policy number

new client Existing client

RuRal application

PAGE 2 nZi, a business division of iaG new Zealand limited RuRal insuRance application Form nZ705/10 02/10

RuRal MateRial DaMageexcess Standard $500 Voluntary $1,000 $2,500 $5,000

inSuRED pRopERtY – BuilDinGS

code Description Year Built

construction Replacement Value $

indemnity Value $

Size Sqm

cover* Office use Only

RV1 Example Implement shed 1980

Concrete & Steel $20,000 $15,000 200 S

Rate prem govt levy

1 $ $

2 $ $

3 $ $

4 $ $

5 $ $

6 $ $

7 $ $

8 $ $

9 $ $

10 $ $

11 003Sundry Buildings – limit $7,500 per building

$ $

sum insured – Buildings $ $

*cover typest = Full Replacement Value (sqm) S = Replacement Value i = actual Value (indemnity)

Full Replacement Value cover is not available for all buildings.

Replacement Value codes Full Replacement Value

RV1

RV2

RV3

RV4

RV5

RV6

Rin

ReX

Farm Buildings

Milking Sheds

coolstores

Grainstores/poultry Sheds

Greenhouses

Horticultural Buildings

indemnity Value

Excess of indemnity

FR1

FR2

FR3

FR4

FR5

FR6

Fin

FeX

Farm Buildings

Milking Sheds

coolstores

Grainstores/poultry Sheds

Greenhouses

Horticultural Buildings

indemnity Value

Excess of indemnity

inSuRED pRopERtY – otHER aSSEtS, pRoDucE, aniMal FEED

code Description Replacement Value $

indemnity Value $

cover Office use Only

Rate prem govt levy

12 009 other assets – contents of buildings, machinery, plant, tools, general stores, wool or milk

$ $ S

13 004 animal Feed – hay, straw, lucerne $ $ S

14 017 produce $ $ i

15 $ $

16 $ $

17 $ $

sum insured Other assets, produce, animal Feed $ $

RuRal application


inSuRED pRopERtY – aDDitional coVERS

code Description Standard cover Sum insured

$

Office use Only

Rate prem govt levy

18 018 artificial Windbreaks $5,000 $

19 cul culverts $5,000 $

20 VEl Deer Velvet $5,000 $

21 013 Fences cover $5,000 $

22 pMp Submersible pumps $7,500 $

inSuRED pRopERtY – optional coVERS

code Description Standard cover Sum insured Office use Only

Rate prem govt levy

23 cEc natural Disaster $

24 SRc additional Sustainable Rebuilding costs

25 BRG Bridges or underpasses $

26 iRR irrigation Equipment

27 lpE live plants $

28 007 livestock $

29 MlK Milk Benefits $10,000

30 Git produce, goods & livestock in transit $25,000

31 Stt Standing timber $

32 oRc orchard trees $

aDDitional coVERSanimal Feed in open Bulk Fertiliser in open

capital additions cover $50,000 Demolition costs cover

Electric Fusion cover $7,500 Employee Effects cover $5,000

Expediting costs cover Fees and other costs

Hazardous Substance Emergency $10,000 increased cost of Working $25,000

increased cost of Working - Sharemilker $25,000 liquidation Bankruptcy & Receivership protection $10,000

Money Extension $2,500 property under construction $50,000

protections costs cover $25,000 Refrigerated Supplies $3,000

Rewards cover Rural Service utilities cover $10,000

Stolen Keys cover $10,000 unharmed property

RuRal application


RuRal Business inteRRuptiOn

SuM inSuRED

code cover Material Damage natural Disaster

Sum insured Rate/premium Sum insured Rate/premium

inploss of insured profit (incl increase in cost of Working)

RRV loss of Rent

DWBDual Wages – 100% for the balance with the option to consolidate to

weeks,

plus %

weeks

Wln Wages in lieu of notice weeks

pDBDual payroll – 100% for the balance with the option to consolidate to

weeks,

plus %

weeks

pFB payroll

aeW additional increased cost of Working

cpc claims preparation costs

232 Book Debts

ROR Rewriting of Records

total

inDEMnitY pERioD

6 months 9 months 12 months other: Months

include Machinery Breakdown Extension? Yes no

note: a sum insured calculation sheet for Business interruption is available at the rear of this application

RuRal application


RuRal MacHineRY BReakDOWn

unSpEciFiED MacHinERY

Electrical and mechanical plant that:• islessthan5kw(6.75hp)

• hasanindividualreplacementvalueoflessthan$2,500

number of Machines Sum insured $ Office use Only

Rate premium

SpEciFiED MacHinERY

code Year Description Sum insured Office use Only

Rate premium

202 $

202 $

202 $

202 $

aDDitional policY EXtEnSionS

code Extension Year Description Sum insured Office use Only

Rate premium

pMp Submersible pump $

pMp Submersible pump $

205 Expediting costs $

excess Standard $500 Voluntary $1,000

RuRal application


RuRal stOck DeteRiORatiOn

code Description of Stock

(produce, bulbs, semen straws etc)

type of Storage chamber

cryogenic Extn Sum insured (current Value)

Office use Only

Rate co. premium

YES no $

YES no $

YES no $

YES no $

total Sum insured

Standard Excess : 10% Voluntary Excess : 20% 30% 50% Does the sum insured for stock represent full current value? YES no

note: it is a requirement of this insurance that all the refrigerated stock must be insured for its replacement value. in the event of under insurance, the insured will be required to be their own insurer for the difference.

is the refrigerating machinery:

(a) maintained by your own engineering staff? YES no

(b) the subject of a regular maintenance contract? YES no

(c) connected to a monitored automatic alarm system? YES no

note: the refrigeration machinery must be insured under a nZi Machinery Breakdown policy.

Do you store goods belonging to others? YES no

is there a reserve generator, or alternative storage facilities, available? YES no

the Meaning of ‘subject to average’1. Your insurance policy contains a provision making it ‘subject to average’.

2. that provision will have effect only if the property insured under the policy is underinsured at the time of loss.

3. if the property insured under the policy is underinsured at the time of loss the following rules apply:

(a) if you suffer a total loss, the provision will have no effect.

(b) if you suffer a partial loss, the maximum amount that you may recover will bear the same proportion to your actual loss as the amount for which the property is insured bears to the full value of the property.

(c) Whatever your loss, in no case will you be entitled to recover more than the amount for which the property is insured.

Example: Your property is worth $20,000. You insure it for $10,000. You suffer a loss of $5,000. If your policy is ‘subject to average’, the maximum amount that you may recover will be $2,500.

RuRal application


RuRal liaBilitY

BRoaDFoRM liaBilitY

annual turnover annual Wages number of Employee’s number of Years on Farm

$ $

cover: Office use Only

$1,000,000 $2,000,000 other $ premium

excess $500is a voluntary excess required? Yes no

$1000 $2500 $5000

autoMatic EXtEnSionS

agricultural contracting - $250,000

Defective Design liability - $250,000

Exemplary Damages - $1,000,000

Food poisoning of animals - $250,000

Hunt club Meetings

loading and unloading liability

Motor Repair or Storage liability - $250,000

product Withdrawal costs (nZ only) - $100,000

underground Services liability

Welding, Gas cutting, Burning off liability

Bailees liability - $250,000

Errors & omissions liability

Farmstay liability

Forest & Rural Fires act - $250,000

landlords liability

Mechanical Mobile plant liability

pollution liability

Roadside Grazing

Removal of Support - $250,000

Office use Only

Do you require cover under the Forest & Rural Fires act in excess of the standard $250,000? Yes no

premium

$500,000 $1,000,000 $2,000,000

Have any circumstances in the last 5 years occurred that could result in a claim under this cover that you are applying for? Yes no

if ‘Yes’, please give details below and/or on a separate page:

Do you ever undertake any work away from your farm? Yes no


Do you ever look after property not belonging to you? e.g. animals, produce, machinery? Yes no


Do you undertake contracting work? Yes no

if ‘Yes’, what percentage of your annual turnover is obtained from contracting? %

RuRal application


Does your contracting work ever involve non agricultural activities? Yes no


StatutoRY liaBilitY

standard cover: $500,000is additional cover required? Yes no

Office use Only

$1,000,000 premium

excess: $500is a voluntary excess required? Yes no

$1000 $2500 $5000



Resource Management actDo you need, or have you ever applied for a resource consent and/or a certificate of compliance under the Resource Management act? Yes no


animal products act & animal Welfare actHave you ever been involved in any investigation or proceedings under, or had compliance notices served upon you, or had fines imposed upon you for any breach of either the animal products act or the animal Welfare act? Yes no


EMploYERS liaBilitY

standard cover: $500,000is additional cover required? Yes no

Office use Only

$1,000,000 premium


$1000 $2500 $5000

number of Employees: Full time: part time: Seasonal:



accare you an ‘exempt’ or ‘accredited’ employer under current acc legislation? Exempt accredited

annual acc levy: $

RuRal application


RuRal cOMMeRcial MOtORgross Vehicle Weight or cc Rating: For cars, utes, vans and light trucks up to 3,500kgs, please provide the engine cc rating (e.g. 2000cc). For trucks, trailers, mobile plant over 3,500kgs, please provide the gross laden weight (GlW).Gross laden weight means the vehicle weight plus load capacity.cover type: please indicate which cover is to apply in the cover column below:c = comprehensive. F = third party, Fire theft & illegal conversion.t = third party only.

item no.

Year of Manufacture

Make, Model & type of Vehicle

Rego. no. Gross laden Weight or cc Rating

Market Value

cover type

ncB Office use Only

Rate prem govt levy

1 $

2 $

3 $

4 $

5 $

6 $

7 $

8 $

9 $

10 $

OptiOnal eXtensiOns

tick where required. please refer to policy wording for full definitions of extension. if an increase to the standard policy limits is required, please provide details.

item 1 2 3 4 5 6 7 8 9 10

303 Foreign objects

312 contracting

SMp agreed Value – Specialist Mobile plant only (Valuation Required)

aMp appreciation – Mobile plant only

RFc liability for Rental Vehicles (Full cover)

RRE liability for Rental Vehicles (Restricted cover)


$1000 $2500 $5000

VFt coDES VFo coDES

cover trucks utes cover tractors plants & implements

unspec.Vehicles

Bikes

Full R3E R3F Full R4a R4B R4J R6a

tpFt R3Z R3Z tpFt R4Z R4Z R4K R6Z

tpo R3X R3X tpo R4X R4X n/a R6X

RuRal application


1. are any of the vehicles ever used for anything other than farming, social or domestic use? Yes no

2. are any of the vehicles designed and used for bulk transportation of inflammable liquids or gases? Yes no

3. Do you carry toxic chemicals, acids, explosives or items considered dangerous? Yes no

4. Do you hire out any of your vehicles without your driver? Yes no

5. are any vehicles used, or intended to be used, airside at any airport? Yes no

6. are the vehicles fitted with any anti-theft devices or fire extinguishers? Yes no

7. Has any vehicle been altered from the manufacturer’s original specifications? Yes no

if you answered ‘Yes’, to any of questions 1 to 7 above, please give details below and/or on a separate page.

8. Where are the vehicles normally housed when not in use? (i.e. locked garage, locked yard, etc)

DRiVeR HistORY

1. Have you previously held motor vehicle insurance? Yes no

if ‘Yes’, please list all insurers for the last 5 years:

inSuRancE coMpanY BRancH pERioD FRoM pERioD to policY (iF KnoWn)

2. Have you had any motor accidents, claims or losses, whether or not the subject of an insurance claim, in the past 5 years? Yes no

DatE oF acciDEnt DEScRiption oF acciDEnt inSuRancE coMpanY total coSt

3. Have you, or anyone else who will drive the vehicles:

(a) Ever been charged with a log book offence? Yes no

(b) Ever had a driver’s licence endorsed, suspended or cancelled? Yes no

(c) Ever been indefinitely disqualified from driving for repeat alcohol or drug related offences? Yes no

if you answered ‘Yes’, to any part of question 3, please give full details below and/or on a separate page:

RuRal application


RuRal incOMe pROtectiOnFull naME occupation D.o.B HEiGHt WEiGHt SMoKER

person 1. Yes no

person 2. Yes no

coVER taKEn: pERSon 1 oFFicE uSE onlY

code Benefit taken sum insured premium

DtH Death cover Yes no $

pDS permanent Disability Yes no $

FDY temporary total Disablement (injury) Yes no $

pDi temporary partial Disablement (injury) Yes no $

FDS temporary total Disablement (illness) Yes no $

MEX Medical Expenses Yes no $

Employment of temporary Staff Yes no $

Deferment period:

1 week (standard) Voluntary period: 2 weeks 4 weeks 8 weeks

coVER taKEn: pERSon 2 oFFicE uSE onlY

code Benefit taken sum insured premium

DtH Death cover Yes no $

pDS permanent Disability Yes no $

FDY temporary total Disablement (injury) Yes no $

pDi temporary partial Disablement (injury) Yes no $

FDS temporary total Disablement (illness) Yes no $

MEX Medical Expenses Yes no $

Employment of temporary Staff Yes no $

Deferment period:

1 week (standard) Voluntary period: 2 weeks 4 weeks 8 weeks

Medical authority: person 1

Doctor:

address:

i authorise you to give nZi any medical information you have regarding me.

Signature: Date:

Medical authority: person 2

Doctor:

address:

i authorise you to give nZi any medical information you have regarding me.

Signature: Date:

RuRal application


Medical History: person 1

Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory, orrespiratorysystems;cancer;arthritisorrheumatism;backorspinecomplaints;hernia;diabetes; abnormalbloodpressure;orheartdisease? Yes no

Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned? Yes no

are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent medical condition or complaint, or have you any physical defect, disability or impairment? Yes no

Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind? Yes no

Have you ever used or injected yourself with any drug not prescribed by a doctor? Yes no

Have you ever been on a programme of drugs, pills or other medication? Yes no

Have you ever had any disorder relating to menstruation or pregnancy? Yes no

are you pregnant? Yes no

if ‘Yes’, expected date of delivery:

if you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:

Medical History: person 2

Have you ever had, suffered from, or been treated for: any disorders of the nervous, circulatory, orrespiratorysystems;cancer;arthritisorrheumatism;backorspinecomplaints;hernia;diabetes; abnormalbloodpressure;orheartdisease? Yes no

Have you ever had, suffered from, or been treated for any health condition or injury not already mentioned? Yes no

are you currently suffering from, or receiving treatment for, any illness, disability, chronic or recurrent medical condition or complaint, or have you any physical defect, disability or impairment? Yes no

Have you ever had or received advice, or treatment for, alcoholism or drug dependence of any kind? Yes no

Have you ever used or injected yourself with any drug not prescribed by a doctor? Yes no

Have you ever been on a programme of drugs, pills or other medication? Yes no

Have you ever had any disorder relating to menstruation or pregnancy? Yes no

are you pregnant? Yes no

if ‘Yes’, expected date of delivery:

if you answered ‘Yes’ to any of the medical history questions above, please give details below and/or on a separate page:

RuRal application


RuRal liVestOck

WoRKinG DoGS

unspecified Working Dogs

number of dogs: @ $750 per dog = Sum insured $

Office use Only

Rate co. premium

specified Dogs

name Gender age*illness & Disease Extn

Sum insured

M/F Yes no $

M/F Yes no $

M/F Yes no $

M/F Yes no $

*note: the policy applies an age limit on the dogs covered of 4 months to 9 years.

WoRKinG HoRSES

code Description of Horse Gender age* Sum insured Office use Only

Rate co. premium

M/F $

M/F $

M/F $

M/F $

M/F $

total Sum insured $

*note: the policy applies an age limit on the horse covered of 12 months to 14 years

are the horses in good health and free from injury, disability, physical abnormality or illness? Yes no

Have any of the horses suffered from any unsoundness or illness in the last 12 months? Yes no

if ‘Yes’, please give details:

note: a veterinary certificate of health must be obtained for any horse valued over $5,000.

RuRal application


liVEStocK

cover Selected: individual animal Herd cover* transit only cover 30 day cover

code Description Species Gender age Sum insured Office use Only

Rate co. premium

M/F $

M/F $

M/F $

M/F $

total Sum insured $

* please attach a schedule of the animals to be insured.

additional cover

code Extension Office use Only

Rate co. premium

707 tuberculosis Yes no

702 Dehorning & Velveting Yes no

709 theft & Escape Yes no

713 unborn offspring Yes no

are the animals in good health and free from injury, disability, physical abnormality or illness? Yes no

Have any of the animals suffered from any unsoundness or illness in the last 12 months? Yes no

if ‘Yes’, please give details:

Were the animals brought at auction during the last 12 months? Yes no

note: a veterinary certificate of health may be required for any animal not bought at auction during the last 12 months.

RuRal application


HOuseindicate cover chosen: nZi Echelon nZi Essence Houseowners Replacement Houseowners present Value

aDDRess OF pROpeRtY

number/Street:

Suburb: town/city:

is property on town water supply? Yes no

What type of Home is this? House Flat/apartment Home unit Body corporate unit

Does this property contain more than one self contained dwelling? Yes no if ‘Yes’, how many?

Who lives there? owner & Family owner & others tenants owner’s Relative/Employee

is the property vacant or unoccupied? Yes no

is the property used as a holiday/weekend home? Yes no

For Flats or units Only

number of flats/units to be insured total number in Block

For tenanted properties Only

1. is the interior inspected by the owner or a professional letting agent at least once every 6 months? Yes no

2. Has there been any damage by tenants (whether insured or not) in the past 5 years? Yes no

3. Do you want to purchase the optional additional Benefit - landlords protection? Yes no

if ‘Yes’, to question 2, please give details below (include date and approximate cost).

please note: • NZIEcheloncoveronatenantedpropertyhasanExcessof$250inadditiontoanyotherExcess,andissubjecttospecificconditions.Pleasereferto

the policy wording for full details.

total Floor area Sq Feet Sq Metres (include all levels plus any outbuildings, developed basement etc.)

Year Built are all exterior walls made of brick or block? Yes no

if built before 1935: Have any of these been done in the last 30 years?

all electrical wiring replaced Yes no

Roof completely replaced Yes no

all plumbing replaced Yes no

all walls re-lined with Gib Board Yes no

completely re-piled Yes no

is there any part of this property:

that is used for any business, trade or profession? Yes no

that has a history of flood or landslip? Yes no

that is damaged or in need of repair? Yes no

that is undergoing renovation or alteration, or that is partially built? Yes no

that is situated in an area with a history of flood or landslip? Yes no

B/o

oFFicE uSE onlY

conStR

RuRal application


Does the property include any of these:

conservatory Yes no Decking over 100m2 Yes no Gazebo Yes no Spa pool Yes no

Swimming pool Yes no tennis court Yes no other (ie jetties, wharfes etc) Yes no

if ‘Yes’ to any of the above please give details below.

Details of any mortgage interests to be noted: (name and postal address)

policY EXcESS

Standard Excess $250 plus additional Voluntary Excess (with premium Discount) $100 $350 $750

SuM inSuRED

if either of the HouSEoWnERS covers have been selected: Replacement Value of property $

if HouSEoWnERS pRESEnt ValuE cover has been selected: present Value of property $

cOntentsindicate cover chosen: nZi Echelon nZi Essence Householders

aDDRess WHeRe cOntents kept

number/Street:

Suburb: town/city:

What is this address? Your usual residence Holiday/Weekend Home Vacant/unoccupied

Who owns the home? You Relative/Employer landlord other(Specify)

if you are not the owner are you:

(a) Sharing with the owner? (b) the only tenant?

(c) Sharing with your spouse and/or family? (d) Sharing with others (not spouse or family)?

if sharing with others (d) how many people live at home in total (including you)?

WHO Will Be cOVeReD? insurance will cover contents owned by the person making this application, and their legally married spouse and any children who live at the address above.

Is Insurance required for Contents owned (or jointly-owned) by anyone else? (eg de facto partner, grandparents etc). if ‘Yes’, you must give their details below or their contents will not be covered. Yes no

SEcuRitY

is the house fitted with a burglar alarm? Yes no

Does it include an external siren? Yes no

Y n

023$Y n Y n

002$MultioFFicE uSE onlY

Y n Y n

n200nMiB

aBRV.St

oFFicE uSE onlY

RuRal application


Was it fitted professionally? Yes no

is it professionally monitored? Yes no

Do all external doors have deadlocks? Yes no

Do all accessible external windows have keyed window locks? Yes no

policY liMitS

itEMS nZi ESSEncE nZi EcHElon HouSEHolDERS

1. Watch or item of jewelleryany item $3,000 $3,000 $1,500

total all items $10,000 $15,000 (jewellery) $10,000

2. camera & photography equipment (including video)any item $2,000 $3,000 $1,500

total all items no limit no limit $3,500

3. Bicycles any item $2,000 $2,000 $1,000

4. Stamps, medals, phonecards, coins, trading cards total each category $750 $1,000 $1,000

5. Money, bullion, precious metals, cut or uncut stones total each category $750 $1,000 $250

6. Home office furniture and equipment (while at the home) total all items not covered $10,000 $1,000

Do you wish to apply for cover above any of these limits? Yes no if ‘Yes’, please give details below:

DEScRiption oF itEM Valuation nuMBER ValuE $

$

$

$

notE: the policies do contain other limits - please refer to the policy wording for full details.

age DiscOunts: please indicate your age group - you may qualify for a discount

up to 49 years 50-59 years 60 years and over

policY EXcESS

Standard Excess $250 plus additional Voluntary Excess (with premium Discount) $150 $400 $750

SuM inSuRED

total insurable value of all contents $

MOtORplease tick which type of vehicle you are insuring car Motor cycle caravan trailer other (Specify)

please tick which type of cover required Standard third party Fire & theft third party only

Make and Model of vehicle: Date of Manufacture:

Registration number: Market Value of Vehicle ($) Engine Size: (cc)

Y n

nalX oFFicE uSE onlY

Y n

nalMoFFicE uSE onlY

Y n

nSRX oFFicE uSE onlY

RuRal application


Fuel type: petrol Diesel transmission: automatic Manual turbo: Yes no Rotary: Yes no

Has the original engine been replaced or modified? Yes no if ‘Yes’, give full details

Have the original wheels been replaced? (other than replacement of tyres) Yes no if ‘Yes’, give full details

Has the bodywork or suspension been modified? Yes no if ‘Yes’, give full details

Has the vehicle been fitted with a stereo system worth more than $1,000? Yes no if ’Yes’, give full details

please tick any of the following which apply to your vehicle Sports or performance convertible/cabriolet Kitset/Replica

left-hand Drive classic/Vintage orphan Hybrid

Does the vehicle have a car alarm or immobiliser? Yes no if ‘Yes’, complete (a), (b) and (c) below

(a) alarm immobiliser

(b) Was the alarm or immobiliser fitted by the manufacturer before the vehicle was sold new in new Zealand? Yes no

(c) advise nZSa Star Rating 1 2 3 4 5

if not rated, give details of system

Where is the vehicle usually parked at night? Garage Driveway/carport on Roadside other (Specify)

Will the vehicle be used in connection with any profession, business or occupation? Yes no if ‘Yes’, give full details

DEtailS oF tHE oWnER(S) & DRiVER(S)

Full naME DatE oF BiRtH SEX (M/F) occupation pHonE

nuMBERDRiVER tYpE (SEE BEloW)

licEncE tYpE (SEE BEloW)

lEnGtH oF licEncE HElD

1. Yrs Mths

2. Yrs Mths

3. Yrs Mths

4. Yrs Mths

5. Yrs Mths

Driver type – Select from: M (Main), R (Regular), n (non driver) licence type – Select from 1 (learner), 2 (Restricted), 3 (Full), 4 (international)

RatEaREaY n

loW KMY n

u25Y n

BRKY n

HFEM F

SEXoFFicE uSE onlY

/ /

DoBY n

naMEDRiVERGRaDinG

RuRal application


DEclaRation QuEStionS

Have you or anyone else who will drive this vehicle had any motor vehicle accidents, damage or theft in the last 5 years (whether a claim was made or not)? Yes no

Have you or anyone else who will drive this vehicle ever indefinitely been disqualified from driving for repeat alcohol or drug related driving offences? Yes no

aDDitional inFoRMation

Do you want to apply for nZi Roadside assist cover? (Standard cover only) Yes no

Do you want a named Drivers Discount? (up to 2 of the drivers listed on page 18 can be named – both must be aged 25 yrs or older) Yes no

if ‘Yes’, please tick the two drivers chosen. 1 2 3 4 5

please note:

• Anyotherdriverswillbesubjecttoanadditionalexcess.

Do you want to exclude all drivers under the age of 25 years for a premium discount? Yes no

please note:

• Thisextensionmaynotbeavailableifwerestrictcovertonameddriversaspartofanyspecialtermstoinsurethevehicle.

Do you want to apply for the low Km option? Yes no

if ‘Yes’, what is the vehicle’s current odometer reading?

please note: • ThisoptionisavailableifyouareapplyingforStandardcover.• Ifyouchoosethisoption,alldriversagedunder25yearswillbeexcludedfromcoverunderthispolicy.

BOatname of craft: type of craft:

Date purchased: price paid: Financier:

Built By: Serial no:

craft length: Year Built: Maximum Speed:

craft construction: GRp GRp (Sandwich) GRp (over wood) Wood Steel aluminium

other – state type:

if self-built – Materials price paid: Estimate labour costs:

Engine Make: number of Engines: Hp:

Engine type: petrol Diesel outboard inboard Stern leg Shaft Drive

other – state type: Year manufactured: Serial no(s):

pREciSE location oF inSuRED cRaFt WHEn not in uSE

lOcatiOn 1

Mooring type/storage location: Mooring number:

lOcatiOn 2

Mooring type/storage location: Mooring number:

RuRal application


SEcuRitY

FiRe eXtinguisHeR(s)

type: number of:

Describe type of trailer anti-theft locking device:

Describe security alarm system:

liSt oF pRopERtY to BE inSuRED

aMOunt insuReD

Hull, fixtures, fittings and machinery (includes outboard motors) $

Mast, spars, rigging and sails (sailboats only) $

Boat trailer make Reg no $

crafts gear (*see definition) plus dinghies, auxilliary outboards etc. $

*crafts gear means the items used with the craft, such as electronic equipment including radio telephones, depth sounders, GpS, chart plotters, marine software, radar, sonar, audio and tV systems, navigation equipment, tenders, outboard motors, warps, ropes, ground tackle, safety equipment, galley appliances and other items which would normally be sold with the craft.

tHe FOllOWing iteMs aRe eQuipMent tO Be insuReD nOt nORMallY puRcHaseD OR sOlD WitH tHe insuReD cRaFt

consumable ship’s stores $

tools $

Fishing gear $

Diving gear $

Wet-weather gear $

total of all categories – total amount insured $

eXplanatiOns• Themaximumamountyouwillbeinsuredforistobeallocatedtothecategoriesshown.

• Whereanamountinsuredisnotshown,coverwillnotapplytothatcategory.

• Theamountsshownforeachcategoryaretheinsurer’smaximumliability.

• Thecraftsgearamountinsuredmustrepresentitstotalvalue.

• Machineryincludesinboard&outboardmotors,gearboxesetc.

• Consumableship’sstoresincludesfuel,food,liquoretc.

eXcess

policy Excess $ Racing Risk Extension Excess $

uSE oF tHE Boat

Will the boat be used for other than private purposes (skippered charter, bare boat charter etc)? YES no

if ‘Yes’, give details

RacinG notE: RacinG coVER iS aVailaBlE SolElY on YacHtS anD tRailER-SailERS

the policy conditions exclude cover for loss to sails, masts, spars or rigging while racing unless optional additional racing cover is taken.

Will the boat be used for racing? YES no

if ‘Yes’, do you require the Racing Risk extension? (optional additional benefit)

RuRal application


uSER EXpERiEncE

Who is the main user of the craft?

Give details of their boating experience

Give details of any accident with any craft the main user has had in the past three years, whether insured or not

Do they have a Boatmasters certificate or similar? YES no

if ‘Yes’, give details

note: to qualify for discount, the Boatmasters or other relevant certificate must be produced.

plEaSE coMplEtE tHE FolloWinG SaFEtY REpoRt

plEaSE anSWER EacH QuEStion BY ticKinG EitHER YES oR no. WHERE a WRittEn anSWER iS REQuiRED plEaSE uSE BlocK lEttERS.

1. are bilge pumps fitted? YES no

2. is a float switch fitted? YES no

3. a) are all underwater through hull fittings equipped with gate valves/sea cocks? YES no

b) are all sea cocks and valves operational? YES no

4. IsthegasstoveinstalledinaccordancewithN.Z.S5428;ieisbottleondeckorincockpitlockervented overboard and are lines of approved material? YES no

5. are fuel tanks externally vented? YES no

6. if petrol engine, is a bilge blower and gas detector installed and operational? YES no

7. are spare anchors carried on board? YES no

8. is there an alternative means of propulsion (oars, paddles, auxiliary motor)? YES no

9. Do you carry a set of flares? YES no

10. Do you hold charts for all the areas in which you operate? YES no

11. is there another fire extinguishing system? YES no

12. is the engine fitted with an audible pressure/temperature alarm system? YES no

13. can you sail a yacht? YES no

14. Have you studied navigation? YES no

15. Have you attended any courses on diesel engines? YES no

16. if on a swing mooring, is it designed for this vessel? YES no

17. is the mooring subject to a current lease issued by a controlling authority? YES no

18. is the mooring lifted from the water and inspected in accordance with regulations or at least once every two years where none apply? YES no

19. are all mooring deficiencies remedied promptly? YES no

nOtes

RuRal application


inSuRancE HiStoRY

please answer each question on behalf of all customers listed above.1. Has any insurance company:

(a) refused to insure any customer, or refused to continue to insure any customer, or

imposed special terms? Yes no

(b) refused any customer’s claim in respect of any insurance? Yes no

2. (a) Has any customer, during the last five years, made a claim in respect of the types of insurance being sought? Yes no

(b) is any customer aware of any circumstances that may result in a claim under any of the types of insurance being sought? Yes no

3. Has any customer (or any director or manager of any customer) been sued for unpaid debts, or managed a company placed in receivership or liquidation? Yes no if you answered ‘Yes’ to any part of questions 1 to 3 above, please give details below and/or on a separate page.

4. Have you or anyone who will drive any vehicle you are insuring:(a) ever been imprisoned for any criminal or driving offence, or

(b) had any conviction or fine for either a criminal or driving offence within the last 7 years, or

(c) any prosecution pending for any criminal or driving offence?

if ‘Yes’, please give full details:

DatE oF conViction natuRE oF oFFEncE aMount oF MonEY inVolVED SEntEncE iMpoSED

5. Does anyone (other than the insured) have a financial interest in any property, machinery or motor vehicles? Yes no

if ‘Yes’, please give details of interested party:

inSuRED itEM DEtailS intEREStED paRtY naME intEREStED paRtY aDDRESS

property

Machinery

RuRal application


Motor Vehicles

plEaSE notE: this information is safeguarded by the privacy act 1993.

inSuRancE coVER taKEn/ not taKEn (cHEcKliSt)

pROpeRtY insuRance Rural Material Damage taken/not takenRural Business interruption taken/not taken

liaBilitY insuRance Rural General (Broadform) liability taken/not takenRural Statutory liability taken/not takenRural Employers liability taken/not taken

cOMMeRcial MOtOR insuRance taken/not taken

OtHeR insuRance income protection taken/not takenMachinery Breakdown taken/not takenStock Deterioration taken/not takenlivestock taken/not taken

peRsOnal insuRanceHouse taken/not takencontents taken/not takenMotor Vehicle taken/not takenBoat taken/not taken

aGREEMEnt

i agree that:

1. MateRial Facts (a) AllinformationgiventoNZI(whetherverbalorwritten)istrueandcorrect;

(b) Allmaterialfactshavebeendisclosed.(See‘YourDutyofDisclosure’);

2. teRMs OF pOlicY ThetermsofNZI’spolicyareaccepted;

3. use OF inFORMatiOn (a) My personal information collected by nZi may be:

(i) usedbyNZItoadvisemeofitsotherservices;

(ii) disclosed to other members of the insurance industry and insurance claims Register ltd., and topartieswhohaveafinancialinterestinthesubjectmatterofthepolicy;

(b) My personal information held by other members of the insurance industry and insurance claims Register ltd., may be disclosed to nZi.

4. agencY anyone who assists me to complete this application Form is acting as my agent only.

On BeHalF OF all applicants Signature Date:

name:

position (Director, Secretary etc.): Date:

pRiVacY act StatEMEnt

We gather information about you (including your claims history) to consider your application for insurance. Your duty of disclosure requires you to do this. if you refuse to provide the information, we may decline your application or declare this policy unenforceable from the beginning.this information is held by us and you may access and seek correction of it. it may be passed on to other insurers you deal with, and interested parties.Your claims history is passed on to, and held by, insurance claims Register ltd. this enables other insurers you deal with to access it, and prevents fraudulent claims.

RuRal application


FoR oFFicE uSE onlY – pREMiuM SuMMaRY

cOMpanY annual pReMiuM cOMpanY FiRst pReMiuM

Rural Material Damage

Rural Material Damage Earthquake

Rural Business interruption

Rural Business interruption Earthquake

Rural General liability

Rural Statutory liability

Rural Employer’s liability

Rural commercial Motor

Rural livestock

total company premium

Flexisteps loading

Government Earthquake

Fire Service levies

Subtotal

GSt

total

Monthly/Quarterly premium

FoR oFFicE uSE onlY – unDERWRitinG

agent no: ........................................ client no: .................................. Review Date: .....................................................................

abbreviated name:.............................................................................. pay plan: ..........................................................................

Service codes: .................................................................................... Months paid: ......................... premium paid: $ .................

office: ........................ By: ............................ occ code: ................. First instalment Date: ............... Receipt no: ........................

unDeRWRiting actiOn acceptance actiOn

Survey on file? no Yes Serviced by code: ..................................

Survey required? no Yes personal authority? no Yes

Ri classification: no Yes Manager authority? no Yes

accum. Reg advice? no Yes Head office uaa? no Yes

Date a.R. advised: no Yes accepted by: ........................................

Reinsurance required? no Yes Date accepted: .....................................

FOR OFFice use OnlY OFFice use FOR FleXisteps OnlY

notes: ..............................................

.......................................................

.......................................................

.......................................................

.......................................................

RuRal application


SuM inSuRED calculation – RuRal BuSinESS intERRuption

Difference Basis net profit & insured Standing charges

turnover $ net profit (before tax)

Plus insured standing charges (non variable) including all wages and salaries unless insured separately.

$

plus closing stock $

less opening stock $

Subtotal $

Deduct uninsured variable working expenses as listed below:

1. purchases $ 1.

2. Wages $ 2.

3. power $ 3.

4. consumable Stores $ 4.

5. cartage $ 5.

6. packing Materials $ 6.

7. Bad Debts $ 7.

8. Discount $ 8.

9. $ 9.

Subtotal $ 10.

Plus allowance for trend in the business anticipated during the next 12 months

$ 11.

12.

13.

Plus allowance for trend in the business anticipated during the indemnity period

Subtotal $

trend $

trend $

inSuRED pRoFit $ inSuRED pRoFit $

nOtes

RuRal application


nOtes

Documents

nZi RuRal insuRance application FoRM · RuRal application nZi, a business division of iaG ew Zealand limited Ru Ral insu ance application Form Z705/10 02/10 PAGE 1 nZi RuRal insuRance