Insured Name e-mail address Contact Person
Street Address City State
Post Code Phone # Fax #

Envelope Draw number of Envelopes Number of final Contestants

Name of Contest/Event

Promotion Period From: To:

Draw Date & Time

Location of final Draw


Post Code

Are Official Rules and/or Regulations for the Contest/Event available?

If “Yes”, please email a copy to

Please provide details on how Participants are selected

Prize Value $ Cash/ Other:

Please provide full details of how prize(s) will be won

Has the Applicant had past experience holding contests/events of this kind?

If “Yes”, please provide an explanation

Has the Applicant previously had similar insurance declined or cancelled?

If you checked “Yes”, please give name of the Insurer and the reason for denial/cancellation

Has the Applicant experienced any losses, within the past five years, under this or any similar type of event, whether insured or not?

If you checked “Yes”, please give all available details regarding the loss

Please provide any further details on the contest/event regarding the loss

This coverage applied for is subject to the warranties, terms, conditions, limitations, exclusions and endorsements of the Insurance Policy to be issued.

By signing below, I acknowledge that I understand that coverage is subject to the warranties, terms,conditions, limitations and exclusions of the Insurance Policy to be issued in addition to the Underwriter’s approval.
I understand that certain clauses contained in the Policy may limit or exclude coverage and that upon receipt of the Policy I should read it carefully. I declare that the information I have provided is complete and true to the best of my knowledge.
I also understand that this application will form a part of the Insurance Policy and that any quote received is only valid for 30 days.
If I am the Broker signing this application on behalf of the Applicant, I certify that I have read the above paragraph to the Applicant who has verified that they acknowledge and understand its contents.

Duty of Disclosure

Before you enter into a contract of general or life insurance with an Underwriter you have a duty, under the Insurance Contracts Act. 1984, to disclose to the Underwriter every matter that you know, or could reasonably be expected to know, is relevant to the Underwriter’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose these matters to the Underwriter before you renew, extend vary or reinstate this contract of general insurance. Your duty, however does not require disclosure of any matter:

  • that diminishes the Underwriter’s risk
  • that is of common knowledge
  • that the Underwriter knows, or in the ordinary course of business, should know
  • as to which compliance with your duty of disclosure is waived by the Underwriter.

If you fail to comply with your duty of disclosure the Underwriter may be entitled to reduce the liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the Underwriter may also have the option of avoiding the contract from its beginning.