Cover Details


Personal Details


Banking Details


Declaration (Please read)


I hereby apply for Legal Cost Insurance on the Policy Terms and Conditions. I understand that the Policy will incept upon payment of the first Premium. I acknowledge that the payment of Premiums on the due dates is my responsibility. I understand that if the debit date falls on a weekend or public holiday, it will be raised on the previous or next business day. I hereby authorise the Insurer and its agent(s) to debit my bank account, with amounts due until cancellation of the Policy. I authorise my bank to treat these payment instructions as if issued by me personally. I undertake to notify the Insurer of any changes to my particulars. I authorise the Insurer and its business partners to access and use of my personal information. I choose the above as my address for service of legal documents. I hereby declare that I am an authorised signatory of the bank account above. I understand that the Legal cost of any Legal Proceeding arising from an Insured Event which occured before the Date of Cover will not be covered. I confirm that I have read this declaration, understand its contents and implications and personally signed it.


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