finance application form - maxxiadoc.maxxia.com.au/document/maxxia/maxmkg_financeapplicationf… ·...

Maxxia Pty Ltd ABN 39 082 449 036 | Authorised Representative (278683) of McMillan Shakespeare Limited (AFSL 299054), Coverforce Insurance Broking Victoria Pty Ltd (AFLS 345986) issuer of lease protection, gap insurance and residual protection cover, Allianz Australia Insurance Limited (AFSL 234708)

ABN 15 000 122 850 issuer of comprehensive insurance, and Eric Insurance Limited (AFSL 238279) issuer of extended warranty product.

Finance Application Form

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1 Personal Information

Mr Mrs Ms Miss Dr First Name

Middle Name Surname

Drivers Licence No. Licence Expiry Date of Birth

Home Phone Mobile Work Phone

Medicare No. Medicare Reference No.

Marital Status: Single Married De Facto No. of Dependant Children (if you have no dependent children please enter 0)

Home Address

Suburb Post Code State

Email

Residential Status: Own / Buying Renting Boarding Time at Address: Years Months

Previous Address (if less than 5 years at current)

Suburb Post Code State

2 Employment Details

Current Employer

Position

Payroll No. / ID Length of Employment: Years Months

Employment Status: Full Time Part Time* Casual / Temp* Contract* Working Hours Per Week

Payroll Frequency Weekly Fortnightly Monthly Next Pay Date:

Contact Name Contact No.

Previous Employer (if less than 5 years at current) Full Time Part Time Casual / Temp

Contact Name Contact No.

Position Length of Employment: Years Months

Lease Term (1, 2, 3, 4 or 5 years) Type of Lease (New, Private Sale, Refinance, Release, Other)

Nationality Status – Permanent Resident Yes No Gross Annual Income $

If No, please provide the following: Proof of Visa, Proof of Expiry Date (Expiry date of Visa to be within Term of Lease)

Personal Reference – Name Contact No.

Relationship to you

(*Please confirm your eligibility with employer)



3 Fuel Card Details (Novated Lease Only) 4 Existing Vehicle (Novated Lease Only)

Three fuel card options available: *Fees and charges apply

BP Caltex* Shell* None Employer provided

Do you have an existing vehicle? Y N

Is the vehicle leased with Maxxia Y N

Are you trading the vehicle in? Y N

Financial Details

Net Monthly Income

Own Income $

Spouse's Income $

Family Allowance $

Rental Income $

Other Income $

Liabilities Balance Monthly Payment / Limit

Home Mortgage $ $

Other Mortgages $ $

Novated Lease Vehicle Loan

$ $

Motor Vehicle Loan(s) $ $

Other Loan(s) $ $

Monthly Expenses

Rent $

General Living Expenses i.e. utilities, phone, food, leisure activities

$

Vehicle Running Costs Leave blank if under a novated lease

$

Private Education / Childcare $

Credit Card Limit What is the total available limit on your credit cards?

$

Assets

Home Value $

Investment Property

$

Motor Vehicle(s) $

Superannuation $

Home Contents $

Bank Balance $

Other Asset(s) $

5

6 Declaration

Have you ever been declared bankrupt or insolvent or are you aware of any current insolvency, bankruptcy or related proceedings, or outstanding judgements or claims against you?

Are any of the assets referred to in Section 5 above held in any trust or by an entity other than you?

If yes, please specify those assets.

Are you aware of any adverse information that may be reported by the credit reporting agency?

Have you ever been known by any other name, including a maiden name? If so, please advise those names.

Name(s)

You agree any fuel card arranged by Maxxia as part of your novated lease must only be used for your novated lease vehicle.

The personal information on this form is collected by us for the purpose of processing your application, administering the product and related services and sending you material about associated products and services offered by Maxxia and its related entities (the McMillan Shakespeare Group of companies). Failure to provide some or all of the information may mean we are unable to process your application. We may disclose the information to the financier, your employer and our related entities, agents, contractors and external service providers. You consent to the financier disclosing personal information about you to a credit reporting agency in order to obtain a consumer credit report and a commercial credit report about you for the purpose of assessing your application for credit and to allow the credit reporting agency to update your credit information file. If you wish to access the personal information we hold about you or do not wish to receive marketing material from us, please contact us on 1300 123 123 or [email protected]. For more information please visit www.maxxia.com.au to view our Privacy Policy.

I have read and understood the particulars that have been completed in this application and confirm that those particulars are true, complete, and have been made to the financier to enable it to assess my finance application.

I confirm that the financial details provided by me in Section 5 above, includes all contingent liabilities (such as guarantees) and all known future liabilities.

Name (please print)

Sign here Date

Y N

Y N

Y N

Y N

Y N


X X

Total Salary Packaging Items Excluding Superannuation

$ $

Per pay Annually



0 1 2 3 4 or more

Insurance Details

ImportantIt is mandatory as part of your novated lease to have your vehicle fully comprehensively insured with an insurer of your choice. If you wish to receive a quotation for comprehensive motor vehicle insurance with Allianz Australia Insurance Limited (AFSL 234708) ABN 15 000 122 850 (Allianz) as part of your novated lease arrangement, please complete the section below. Maxxia is an authorised representative of Allianz.

The following questions should be answered carefully and in full by the novated lease lessee only. The lessee will be listed as the primary driver under the insurance policy, regardless of whether the lessee is the majority driver. The policy generally covers other drivers of the vehicle, although additional excesses may apply depending on driver age. The information on this form will be used to provide you with a quotation and, if you purchase insurance, will form part of your contract with the insurer. Should you proceed to purchase this policy, the start date of your insurance coverage will coincide with the date that you take delivery of your vehicle.

Driver history

1. In the last five years, have you had any claims where you were at fault?

Note: An at fault claim is any claim where you were required to pay an excess, including claims resulting from weather (eg. hail damage), wildlife, and/or where the third party responsible was not identified

If YES, how many?

2. In the last five years, has any insurer refused to insure any motor vehicle for you or any person who will or is likely to drive your vehicle(s)?

3. In the last three years, have you or any person who will or is likely to drive any of the vehicles listed:

(a) been convicted of, or had any fines or penalties imposed for any driving related alcohol/drug offences?

(b) had their drivers license cancelled, suspended or disqualified?

(c) been convicted of, or had any fines or penalties imposed for, any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?

Insurance renewals

Please tick this box if you would like to receive your comprehensive insurance renewals via email only.

Privacy

Maxxia is committed to protecting your privacy. The information you provide is used by the insurer to assist in deciding whether to insure you and on what terms. Maxxia and not a third party provides your information to the insurer (and their representatives). The insurer may exchange this information with other insurers or insurance reference services. Maxxia may also use your information to provide you with updates about other products and services, including financial products and services. Maxxia do not trade, rent or sell your information. You can check the information Maxxia hold about you at any time. For more information about our Privacy Policy, ask us or refer to www.maxxia.com.au.

Declaration by the applicant

1. I have read and understood my Duty of Disclosure as detailed in the Product Disclosure Statement (PDS).

2. I declare to the best of my knowledge and belief that the information given on this form is true in every respect.

3. I agree that this application and declaration shall form part of the contract between myself and the insurer.

Name (please print):

Signature: Date:

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Yes No

Yes No

Yes No

Yes No

Yes No


This document must be physically signed.

finance application form - maxxiadoc.maxxia.com.au/document/maxxia/maxmkg_financeapplicationf… ·...

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