RICNOX TAXI CLUB PTY LTD
Email address *
APPLICANT DETAILS
DRIVER DETAIL AND MEMBER APPLICATION
Name of Registered Operator: *
Your answer
Mailing Address: *
Your answer
Contact Telephone: *
Your answer
Email: *
Your answer
D.O.B.: *
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Driver’s Licence No: *
Your answer
Date of Expiry: *
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Company Name: *
Your answer
ABN: *
Your answer
Mailing Address: *
Your answer
Contact Telephone: *
Your answer
Email: *
Your answer
DRIVER DETAILS
Full Name: *
Your answer
Mailing Address: *
Your answer
Contact Telephone: *
Your answer
Email: *
Your answer
D.O.B.: *
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Driver’s Licence No: *
Your answer
Date of Expiry: *
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Document provided: *
You must provide certified colour photocopies of: any driver’s licences, registrations, accreditation, passport (if not an Australian Citizen) and a rates notice/utility bill/bank statement with their name and address.
Your answer
Driver Accreditation Number: *
Your answer
How many years have you been driving taxis? *
Your answer
Are you currently covered or insured? If YES, by whom? *
If yes provide detail otherwise simply enter No
Your answer
How many years have you owned a taxi? *
Your answer
APPLICANT’S DECLARATION
Following acceptance of my membership application form, We/I agree to abide by the rules and guidelines of MPTCIas set out in the Terms of Engagement which We/I have read and understood.We/I understand that the benefits offered under this Agreement are at the discretion of the Secretary of MPTCIand are contingent upon the veracity and verification of this declaration. We/I have not withheld any information that may affect the acceptance of this application or be regarded as reckless to the taxi industry or an unacceptable risk.
DUTY OF DISCLOSURE
When answering the questions,you must be honest and disclose anything you know or should know which could affect the Insurer (QBE), or set terms on which they will insure you. Failure to disclose information could result in the refusal to pay a claim.
Name: *
Your answer
Address: *
Your answer
Taxi Plate Number: *
Your answer
Start Date: *
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ABN: *
Your answer
Phone: *
Your answer
Limit of Liability: $10,000,000 *
Have you had any claims made against you in the past 10 years for any reasons? *
If yes provide detail otherwise simply enter No
Your answer
Have you had any incident or accident occur which would have been covered by the proposed Insurance Policy for the last 5 years ? *
If yes provide detail otherwise simply enter No
Your answer
Have you had any Insurance declined or cancelled, Proposal rejected, renewal refused, Claim rejected, or special conditions imposed by an insurer for the four years? *
If yes provide detail otherwise simply enter No
Your answer
PROPOSED DATE COVER IS TO COMMENCE: *
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VEHICLE PARTICULARS
TAXI VEHICLE DETAILS:
Vehicle Make: *
Your answer
Vehicle Model: *
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Year of vehicle: *
Your answer
Registration Number: *
Your answer
Engine No: *
Your answer
Current kilometres (KM/Odometer) reading: *
Your answer
Company & Radio No. of Taxi: *
Your answer
Date vehicle first registered as a Taxi: *
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Purchase price:$ *
Your answer
Car financed/lease details: *
If yes provide detail otherwise simply enter No
Your answer
Is there any unprepared damage to your vehicle prior to commencement of cover? *
If yes provide detail otherwise simply enter No
Your answer
I have gone through all above questions carefully and I am agree. *
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