Truck Insurance Form

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If there is insufficient room on the form please provide additional information via email to david@galvaniize.com.au.

FILL OUT FORM

Truck Insurance Form

"*" indicates required fields

Step 1 of 14 - Section 1

SECTION 1: COMPANY DETAILS

Company/Policyholder name*

Email*

Address*

State*

Postcode*

Phone number*

COMPLETING THIS FORM:

This form is designed to allow us to consider additional information in respect of a driver. Sections 2 to 10 below are for completion by the driver themselves. Sections 11 & 12 below are for completion by the insured.
Both Driver and Insured areas MUST be completed and signed to process this application

SECTION 2: DRIVER DETAILS

Driver’s name*

Date of birth*

DD slash MM slash YYYY

Driver's Email*

Address*

State:*

Postcode*

Phone number*

SECTION 3: LICENCE DETAILS

LICENCE CATEGORY

Car

Car License Years Held

Car License State of Issue

Car License No.

Car License Expiry Date

MM slash DD slash YYYY

Light Rigid

Light Rigid License Years Held

Light Rigid License State of Issue

Light Rigid License No.

Light Rigid License Expiry Date

MM slash DD slash YYYY

Medium Rigid

Medium Rigid License Years Held

Medium Rigid License State of Issue

Medium Rigid License No.

Medium Rigid License Expiry Date

MM slash DD slash YYYY

Heavy Rigid

Heavy Rigid License Years Held

Heavy Rigid License State of Issue

Heavy Rigid License No.

Heavy Rigid License Expiry Date

MM slash DD slash YYYY

Heavy Combination

Heavy Combination License Years Held

Heavy Combination License State of Issue

Heavy Combination License No.

Heavy Combination License Expiry Date

MM slash DD slash YYYY

Multi Combination

Multi Combination License Years Held

Multi Combination License State of Issue

Multi Combination License No.

Multi Combination License Expiry Date

MM slash DD slash YYYY

SECTION 4: LICENCE INFRINGEMENT PRINT OUT

To support this declaration please attach a FULL DRIVER LICENCE HISTORY PRINT OUT from your state or territory Transport Authority. Please note on the driving history if the infringement was incurred in a vehicle over 2 tonnes or under 2 tonnes carrying capacity or in a Car.

Please note we cannot process this form without this print out.

If you have held a licence in another state, territory or country other than your current residence, please supply a print out from that state, territory or country

Upload print out

Max. file size: 128 MB.

SECTION 5: DRIVING EXPERIENCE

Please tick the licence category of the vehicle you will be driving in this job, and fill in how many years’ experience you have driving this licence class of vehicle in Australia and the average distance travelled per journey

MC Driving Years

MC Average Distance Travelled per Journey

200 kms

450 kms

850 kms

Over 850 kms

HC Driving Years

HC Average Distance Travelled per Journey

200 kms

450 kms

850 kms

Over 850 kms

HR Driving Years

HR Average Distance Travelled per Journey

200 kms

450 kms

850 kms

Over 850 kms

MR Driving Years

MR Average Distance Travelled per Journey

200 kms

450 kms

850 kms

Over 850 kms

LR Driving Years

LR Average Distance Travelled per Journey

200 kms

450 kms

850 kms

Over 850 kms

How many kms per week were you averaging driving this class of vehicle over the last year? (kms per week)*

What kind of freight were you carrying?*

What were the primary route/s?*

SECTION 6: HEALTH

Have you had a medical examination in the last 12 months?*

Yes

If no, when was your last medical examination? (years/months ago)*

If yes, were you declared fit to drive a Commercial Motor Vehicle?*

Yes

Did you test positive to diabetes, sleep apnea or another significant medical condition which is reasonably likely to impact your driving capability if not satisfactorily managed?*

Yes

If yes, is the condition managed to the satisfaction of the medical practitioner, enabling you to drive a heavy vehicle?*

Yes

SECTION 7: DRIVING HISTORY IN THE LAST 10 YEARS

Have you ever been convicted for

Driving under the influence of alcohol?*

Yes

If yes, what kind of vehicle were you driving?

Truck

Car

Driving under the influence of drugs?*

Yes

If yes, what kind of vehicle were you driving?

Truck

Car

Have you ever been convicted of road rage?*

Yes

Driving dangerously, at fault, negligently or without due care?*

Yes

Speeding at 15 – 30 km/hr or more over the posted limit in the last 2 years?*

Yes

Have you ever had your licence endorsed, suspended or cancelled?*

Yes

Have you held a different interstate licence, other than the licence number stated on this form, within the last 5 years?*

Yes

Have you ever been convicted of a criminal offence in the past 10 years (5 years if juvenile)?*

Yes

Have you ever been convicted of a drug offence in the past 10 years (5 years if juvenile)?*

Yes

If you have been convicted of a criminal offence please attach a copy of your national police clearance (i.e. criminal history) print out from the relevant authority.

Max. file size: 128 MB.

SECTION 8: ACCIDENT HISTORY IN LAST 5 YEARS

Have you ever had a Motor Vehicle accident?*

Yes

What kind of vehicle were you driving?

Truck

Car

Were you found by police and investigators to be at fault?*

Yes

Was it a:*

single-vehicle accident

multi-vehicle accident

If you answered yes, please provide the following:

Accidents

Date

Time of Day

Description

Approx. Cost of Damage ($)

Vehicle Type (ie. Truck, Car, etc)

Who was at Fault?

Add more

SECTION 9: TRAINING HISTORY

Have you ever undertaken formal Fatigue Management Training?*

Yes

If so, who supplied the training? (Company name)

When was the training undertaken?

DD slash MM slash YYYY

Please provide details of any other training you have completed, or are currently completing:

Additional Courses

Course Name

Course Date

DD slash MM slash YYYY

Are you still taking the course?

Completed

Currently Completing

Company / Personally Funded?

Company Funded

Personally Funded

Add more

SECTION 10: RECENT EMPLOYMENT HISTORY

Please provide details for the last five (5) years (starting with the most recent):

Employment History

Company name

Location

Start Date

DD slash MM slash YYYY

Finish Date

DD slash MM slash YYYY

Employment History 1 Type of freight carried:

Employment History 1 Average kms travelled per week:

Type of vehicle driven:

Add more

SECTION 11: INTENDED DRIVER ACTIVITY

Reg No. of Vehicle

Sum Insured

Forward Facing Camera Fitted

GPS Fitted

Furthest Normal Destination

% of Working Hours Between Midnight & 6AM

Avg Weekly KMS

Circle Freight Task*

General Freight

Machinery

Tipping

Livestock

Refrigerated

Dangerous Goods (i.e. Fuel)

If unit is articulated select configuration*

Semi Trailer

B Double

B Triple

Double Road Train

Triple Road Train

Quad Road Train

Pocket Road Train

Will the driver be engaged in ‘Two Up’ operation?*

Yes

Do you conduct route induction?*

Yes

Operational Routes:

Route

From

Via

Highway(s) Used

Add more

SECTION 12: COMPANY TRAINING

Describe training that will be supplied to this driver

Details 1:*

Details 2:

Details 3:

SECTION 13: MISC INFORMATION

If there is anything else you would like to tell us to assist in the review of this application please write here.

PRIVACY STATEMENT

The Privacy Act 1998 (as amended) now applies and requires us to inform You that;

Purpose of collection
We collect personal information (this is information or an opinion about an individual whose identity is apparent or can reasonably be ascertained and which relates to a natural living person) for the purpose of acceptability as a driver of a Motor Vehicle under a policy. The personal information collected can be used or disclosed by us for a secondary purpose related to the purpose listed above, but only if you would reasonably expect us to use or disclose the information for this secondary purpose. However for sensitive information, the secondary purpose must be directly related to the purpose listed above.

Disclosure
We may disclose your personal information, when necessary and in connection with the purposes listed above, to; Your Employer’s insurance broker or an agent of NTI Limited, Government bodies, loss assessors, claim investigators, reinsurers, other insurance companies, claims reference providers, other service providers, hospitals, medical and health professionals, legal and other professional advisers

Consequences if information is not provided
If you do not provide us with the information we need, we will be unable to consider your application as a driver of a Motor Vehicle under a policy.

Access If you request access or wish to update the information we hold about you, please contact your nearest NTI office.

Declaration
I hereby declare that I have read the privacy statement above and consent to the collection of the above information by NTI. I hereby declare and warrant that I have read this questionnaire and that the answers above are in every respect true and correct and that I have not withheld any material information. I also agree at the request of NTI to obtain from the relevant authority or Government department a complete and up to date record of offences.

Driver’s Signature:*

Date*
DD slash MM slash YYYY

I/We understand that no insurance for any vehicle in the control of the above-stated driver is in force until such time that this Driver Declaration is approved in writing by National Transport Insurance to include cover for this driver under this policy

Insured’s Signature:*

Date*
DD slash MM slash YYYY

NB: This application is not valid unless signed & dated by both the Insured and Driver.

Galvaniize Pty Ltd ABN 26 600 154 354 CAR 471763 Corporate Authorised Representative and David McEwan AR 471764 Authorised Representative of Community Broker Network Pty Ltd T/As Community Broker Network ACN 096 916 184 AFSL 233750 are a Steadfast Group Limited subsidiary. Steadfast are a public listed company and listed on the Australian Stock Exchange.

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Truck Insurance Form

Please fill out form and submit