Apply for Income Protection Insurance

PERSONAL INFORMATION
Name of Insured*
First Last
Address of Insured*
Street Address Address Line 2 City State Post Code
Contact Phone Number*
Email Address*

INSURANCE DETAILS
Date that cover is required to commence*
Height of insured (cms)*
Weight of insured (cms)*
Occupation*
Provide brief details of your work role*
Are you a permanent resident of Australia?*
Do you require cover for any hazardous pastimes or pursuits?*
Please provide details here*
Do you have any cause to consider yourself not in good health?*
Please provide details here*
Have you smoked in the last twelve months?*
Are you taking any medications (both prescription and non-prescription)?*
Please provide details here*
Do you have any pre existing conditions?*
Please provide details here*
Have you been treated by a registered medical practitioner (i.e. Doctor , Nurse, Physiotherapist, Psychiatrist etc) for any Injury or Sickness in the past 5 years that required hospitalisation, time off work, or ongoing treatment?*
Please provide details here*
Do you currently hold or previously held any Personal Accident insurance?*
Please provide details here*
Have you had any Personal Accident insurance and/or WorkCover claims in the last three (3) years?*
Please provide details here*
Have you been declined insurance in the past?*
Please provide details here*

BENEFITS REQUESTED
1. Accidental Death
Sum Insured $ 24 Hour Cover Working Hours Only Outside Working Hours Only
2. Disablement
Sum Insured $ 24 Hour Cover Working Hours Only Outside Working Hours Only
3. Weekly Injury Benefits
Sum Insured $ 24 Hour Cover Working Hours Only Outside Working Hours Only
4. Weekly Sickness Benefits (24 Hour Cover Only)
Sum Insured $ 24 Hour Cover Working Hours Only Outside Working Hours Only
5. Broken Bones
Sum Insured $ 24 Hour Cover Working Hours Only Outside Working Hours Only

Important Information

Privacy Policy
Safe Hands Insurance Group Pty Ltd T/As DJ Insurance Services (ABN: 69 163 926 261 AR No 4400038 as Authorised Representative of Winley Insurance Group Pty Ltd ACN 138 133 285 ABN 39 138 133 285 AFS Licence No 343573), is committed to protecting your privacy in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. Our Privacy Policy describes our current policies and practices in relation to the collection, handling, use and disclosure of personal information. It also deals with how you can complain about a breach of the privacy legislation and also, how you can access the personal information we hold and how to have that information corrected. Please visit This Link to download our full privacy policy.
Your Duty of Disclosure
What you need to disclose:
Before you enter into a contract of general insurance with us, you have a duty under the Insurance Contracts Act 1984 to disclose every matter that you know, or could reasonably be expected to know that would be relevant to the insurer’s decision whether to accept the application of the insurance and, if so, on what terms and conditions.
What you are not required to disclose Your duty does not require disclosure of any matter:
1. That diminishes the risk to be undertaken by us;
2. That is of common knowledge;
3. That we know or, in the ordinary course of our business, ought to know;
4. Where compliance with this duty is waived by us.
Consequences of non-disclosure
If you fail to comply with your duty of disclosure obligations and/or have not answered the questions honestly in your application and not advised what you, as a reasonable person in the circumstances would have answered, the insurer may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract.
Fraudulent non disclosure and its consequences
If your non disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning - i.e. treat the agreement as if it never existed.
Subrogation
You may prejudice your rights with regard to a claim if, without prior agreement from the Insurer, you make agreement with a third party that will prevent the Insurer from recovering the loss from that, or another party. Your policy contains provisions that either exclude the Insurer from liability or allows them to reduce their liability in the event that you have entered into any agreement that excludes your rights to recover damages from another party in relation to any loss, damage or destruction which would otherwise allow you to sustain a claim under this policy.
1. I have read and understand the Duty of Disclosure Information*
- Yes
2. I have read and understand the Subrogation Clause*
- Yes

Personal Accident

Step 1 of 4

PERSONAL INFORMATION

INSURANCE DETAILS

BENEFITS REQUESTED

Important Information

Privacy Policy

Your Duty of Disclosure

Subrogation