GWS Motor Vehicle Driver Declaration

Driver Details

Driver History

Questions below relate to the past 5 years:
Had a motor vehicle accident and/or made a claim under a motor vehicle policy?*
Been refused insurance or had a policy cancelled or had a compulsory excess imposed?*
Been convicted or fined for any traffic offence or had a driving licence endorsed or cancelled?*
Have any physical defect or infirmity which would affect the driving of a motor vehicle?*
Do you have any criminal convictions, findings of guilt and/or pending charges (non-traffic) against you?*
Is there any other information which is relevant to the insurer in accepting this insurance?*

Signature

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    Date: 09/12/2023
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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with COVERMORE by calling 1300 728 822.
    •  If you need to make changes to the policy, you will need to contact COVERMORE on 1300 728 822.

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with CHUBB by calling 1800 803 548.
    •  If you need to make changes to the policy, you will need to contact CHUBB on 1800 803 548..

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with EMERGENCE by calling 1300 799 562.
    •  If you need to make changes to the policy, you will need to contact EMERGENCE on 1300 799 562

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    By purchasing online:

    •  You are expected to self-manage your policy.
    •  There is no advice provided by Austbrokers Countrywide.
    •  You will need to manage your own claims directly with Austbrokers Life Solutions by calling 1300 161 635.
    •  If you need to make changes to the policy, you will need to contact Austbrokers Life Solutions on 1300 161 635.

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