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Vmia certificate of insurance... ABN ACN Sole Traders or Partnerships The ABN provided cannot be associated with a Trust Companies The ACN must be provided SECTION 2. Vmia.vic.gov.au Victorian Managed Insurance Authority ABN 39 682 497 841 PO Box 18409 Collins Street East Victoria 8003 P 1300 363 424 SECTION 3. Phone Number 1800 633 467 Website www. hiainsurance. com.au Risk Management and Insurance CERTIFICATE OF INSURANCE APPLICATION You can now purchase DBI online using this form From 1 July 2017 Builders can manage and purchase Domestic Building Insurance DBI via the online portal BuildVic. Builders who do not wish to purchase DBI via BuildVic will need to complete this form and submit the application to their nominated DBI distributor for processing. important Your must contact the DBI Distributor immediately if there has been any change to your eligibility details. PROJECT TYPE C01 New Single Dwelling C03 New Multi-Dwelling Construction C05 Swimming pool C06 Refurbishment Non structural C04 Alteration/Additions/ Renovations structural contains structural works Other please specify e.g. landscaping retaining wall Have works already commenced on this project by another builder No Yes describe the scope of work to be covered by this certificate of insurance application e.g. contract to complete dwelling from frame stage to completion Page 1 of 5 office use only COI-APP 0717-6 dbi. I have read and agree to the VMIA s terms and conditions for the provision of DBI a copy of which can be found at www. Card Number CCV Number Name on Card Card Expiry mm/yyyy Signature Date dd/mm/yyyy To the extent permitted by law we may correspond with you by electronic communication unless you instruct us not to do so and vice versa. A copy of the HIAIS Privacy Notice can be located on our website www. hiainsurance. com.au PAYMENT DETAILS FOR CERTIFICATE OF INSURANCE A premium is payable on submission of this application form. Please enter your credit card details in the section below. Credit Card Type Mastercard Visa I authorise the fee / premium of to be deducted from my nominated credit card. Dbi. vmia.vic.gov.au I authorise on my own behalf and on behalf of the Builder and its partners and directors a the VMIA disclosing the Builder s personal information and the directors and partners of the Builder s personal information and any other information provided by the Builder or directors and partners of the Builder including but not limited to any information contained in any application for eligibility for DBI Insurance or application for DBI Insurance or in relation to any claims or recoveries in relation to DBI Insurance including the Builder s and the directors and partners of the Builder s claims and credit history to or obtaining such information from other insurers insurance intermediaries DBI Distributors insurance reference bureaux credit reference agencies VMIA s advisers or report on the building industry or on building works undertaken or to be undertaken by the Builder those involved in the claims handling process including assessors and investigators those involved in any way in connection with building work insured under any DBI insurance the owners of any building work undertaken by the Builder which is insured by the VMIA which may include any successor in title to the owner for whom the work was undertaken family members or agents authorised by me or the Builder eligible for DBI insurance and people making enquiries for details of any DBI Insurance issued in respect of a nominated property for the purpose of assisting the VMIA and them in providing relevant reporting regulation services and products or for the purposes of litigation DBI Insurance policy number date of certificate of insurance address of building site name of Builder whether a claim has been made and the amount of any indemnity remaining under the DBI Insurance policy limits.

Occupational accident insuranc... All Risks, Ltd. 11811 North Tatum Blvd, Ste 4010, Phoenix, AZ 85028 Toll Free: 8004189763 Fax: 6023242306 www.allrisks.comQUESTIONNAIRE Occupational Accident Insurance NOTE:There are six sections

Group term life insurance appl... Group Term Life Insurance Application Please complete and return this form to: Worldwide Assurance for Employees of Public Agencies (WA EPA) 433 Park Ave., Falls Church, VA 22046 (800)3683484 www.waepa.org

Ireland health insurance appli... Apply for ERIC How to apply for your European Health Insurance Card 1. Apply online if you already have either a medical card or a Drugs Payment Scheme (DPS) card 2. Apply in person by completing

Individual life insurance appl... Individual Life Insurance Application for Reinstatement with Evidence of Insurability Interstate Compact states Good Order Checklist: Use this checklist to make sure you have provided all the information

Long term care liability insur... TDC Specialty Insurance Company (hereafter, the Underwriter) A wholly owned subsidiary of The Doctors Company Servicing Address: 1888 Century Park East, Suite 850 Los Angeles, CA 90067Procedure Questionnaire THIS

Health insurance application f... Generali Worldwide Health Plan Medical Questionnaire Gastrointestinal Please complete all sections in BLOCK CAPITALS or tick the boxes, where appropriate.Group Number: Employer Name: Employee Name:Employee

Globe life insurance applicati... Application for Reinstatement United Home Life Insurance Company ? 225 S. East St. ? P.O. Box 7192 ? Indianapolis, IN 46207-7192 ? 1-800-428-3001 Policy Number Proposed Insured Premium Collected Spouse

Marine insurance application f... Motor ID Year Value Dinghy ID Year Value Dinghy Motor ID Year Value Not covered unless itemized Total Hull and Machinery Value Premium Additional Personal Effects/Fishing Equipment Attach List Value Premium Trailer ID Year Value Premium Optional Coverages Premium Loss Payable Name Liability 300 000 Included City State Zip Liability 1 million Policy Fee 55 Hull Deductible Total Premium List all Operators of the Vessel List all auto moving traffic violations and at fault accidents per operator Name date of birth years experience use drivers license In the past 3 years date of accident date of conviction description of incident license revoked 1 Where is Boat Moored Where Laid up Ashore Afloat Is Boat Transported Over Land Yes No How far How often Type of Vessel Sailboat Trawler Cruiser High Performance Houseboat Runabout Other Does Yacht have Sleeping Quarters Galley Head Radar Compass Depth Finder SS Radio Propane Live Aboard Yes No Loran GPS Head Autopilot Vapor Detection System Built in CO2 or Halon System Fire Extinguishers Is Yacht of Fiberglass Construction Yes No Specify Fuel Type Gas Diesel Max Speed Of Engines Manufacturer Inboard Outboard I/O Jet Total HP Any Chartered Use Yes No Navigation Limits Requested Insurance ever Refused or Cancelled No Yes Reason Please Read Before Signing Application This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed if necessary by a supplement to the application. A consumer report containing personal credit factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk but it is agreed that this form shall be the basis of the contract should a policy be issued. Signature of Applicant Signature of Agent Date ALT Insurance Group Lafleurinsurance aol.com 253-536-2403 Agent s Firm Agent Return Fax Return E mail NOTE INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER Binders expire 15 days from the effective date unless payment is received by Premier Marine within the binder period. 800 FIFTH AVENUE SUITE 4100 SEATTLE WASHINGTON 98104 TOLL FREE LINE 1 800 589 4208 FAX 1 800 522 4461. PREMIER MARINE INSURANCE Application for Insurance Ocean Marine Insurance Quote Only Please Bind Insured Phone Wk Hm Address City State Zip Date of Birth Occupation Employer No. of Years as owner of a boat No. of Years as Operator/Crew Insurance Effective Date Previous Insurer This or prior boats Policy Exp Date Size and Type of Previous Boats Member of Cruising Club Date of Marine Survey Boating Education and Courses Boating Losses in last 3 years claimed or not date description Coverages Hull Machinery Make Model Year Serial Registration Length Date Purchase Replacement Current Purchased Price Cost New Market Value Outboard or Aux. Motor ID Year Value Dinghy ID Year Value Dinghy Motor ID Year Value Not covered unless itemized Total Hull and Machinery Value Premium Additional Personal Effects/Fishing Equipment Attach List Value Premium Trailer ID Year Value Premium Optional Coverages Premium Loss Payable Name Liability 300 000 Included City State Zip Liability 1 million Policy Fee 55 Hull Deductible Total Premium List all Operators of the Vessel List all auto moving traffic violations and at fault accidents per operator Name date of birth years experience use drivers license In the past 3 years date of accident date of conviction description of incident license revoked 1 Where is Boat Moored Where Laid up Ashore Afloat Is Boat Transported Over Land Yes No How far How often Type of Vessel Sailboat Trawler Cruiser High Performance Houseboat Runabout Other Does Yacht have Sleeping Quarters Galley Head Radar Compass Depth Finder SS Radio Propane Live Aboard Yes No Loran GPS Head Autopilot Vapor Detection System Built in CO2 or Halon System Fire Extinguishers Is Yacht of Fiberglass Construction Yes No Specify Fuel Type Gas Diesel Max Speed Of Engines Manufacturer Inboard Outboard I/O Jet Total HP Any Chartered Use Yes No Navigation Limits Requested Insurance ever Refused or Cancelled No Yes Reason Please Read Before Signing Application This application will be incorporated in its entirety into any relevant policy of insurance where Insurers have relied upon the information contained herein. Any misrepresentations or concealment in this application for insurance will render insurance coverage null and void from inception. Please therefore check to make sure that all questions have been fully answered and that all facts material to your insurance have been disclosed if necessary by a supplement to the application. A consumer report containing personal credit factual or investigative information about the applicant may be sought in connection with this application for insurance or any renewal extension or variation thereof. Signing this form does not bind the Applicant to purchase the insurance or the Insurer to accept the risk but it is agreed that this form shall be the basis of the contract should a policy be issued. Signature of Applicant Signature of Agent Date ALT Insurance Group Lafleurinsurance aol.com 253-536-2403 Agent s Firm Agent Return Fax Return E mail NOTE INSURANCE IS NOT IN EFFECT UNTIL PREMIER HAS ISSUED A BINDER NUMBER Binders expire 15 days from the effective date unless payment is received by Premier Marine within the binder period.

Allstate insurance application... M. to 8 00 P. M. Eastern Standard Time. The furnishing of this form or its acceptance by the Company as proof must not be construed as an admission of any liability on the part of the Company nor a waiver of any of the conditions of the insurance contract. POLICYHOLDER / CERTIFICATEHOLDER Insured s Name Patient Policy Number s 1 Male Female Insured s Social Security Number Patient s Date of Birth / MO/DAY/YR Home Number E-mail Filing a claim for ...

Allstate insurance application... M. to 8 00 P. M. Eastern Standard Time. The furnishing of this form or its acceptance by the Company as proof must not be construed as an admission of any liability on the part of the Company nor a waiver of any of the conditions of the insurance contract. POLICYHOLDER / CERTIFICATEHOLDER Insured s Name Patient Policy Number s 1 Social Security Number Date of Birth / Male Female MO/DAY/YR Home Number E-mail Filing a claim for your calendar year W...

Home insurance application for... RESET FIELDS Please fill in Completely. HOMEOWNERS/DWELLING FIRE/CONDO APPLICATION (3/09) Quote Number Check One POLICY PERIOD HOA HOB HO1 HO2 HO4 HO6 HO8 DP-1 TO Same Date 12 months PRIMARY SECONDARY

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