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EXTENDED WARRANTY INSURANCE

Proposal & Policy Schedule


Please provide all Information requested and answer all questions fully to enable us to process your warranty. If there is insufficient space provided for any details please attach a separate sheet of paper. Agent Details Dealer Name POMI Dealer No. RA00011 Insured Details
First Insured Title First Name Last Name Address Postcode Home Phone Business Phone Mobile Phone Email Address Date of Birth ABN Registered for GST MR. JAMES A 14 ASNITA ZARA NEW SOUTH WALES 2484 1487878788 Second Insured Title First Name Last Name Address Postcode Home Phone Business Phone Mobile Phone Email Address Date of Birth ABN Registered for GST

Policy Number: 0003001221

ISN

A01982

01/01/1980 No

Corporate Details
Company Name Address Suburb State, Postcode Business Phone ABN Number Registered for GST

Vehicle Details
Make Model Compliance Year Reg No. ABARTH 500 CONVERTIBLE 2013 AS410 VIN Number Drive Type Odometer at purchase Vehicle Use 11/07/2013 11/07/2013 ESANDA - ANZ BANKING GROUP LIMITED A1401 12000 PRIVATE Body Type Cylinders Transmission Fuel Type 12 0 11/07/2013 CONVERTIBLE T4 5 SP AUTOMATED MANUA

Factory Warranty Start date Vehicle Purchase Date Financier (if financed) Vehicle Modifications

Factory Warranty Length (mths) Statutory Warranty Length (days) Date First Registered

Cover Term
Type of Cover Vehicle Use Dealer Service Waiver 12 Months PRIVATE NO EXTENDED WARRANTY SILVER Vehicle Class Period Of Insurance B From: 11/07/2014 To: 11/07/2015

Premium Details
Premium Details Net Premium GST on Premium Stamp Duty Establishment Fee Total Premium . Declaration by Insured Person(s) I/We the undersigned declare that; I/We have answered all questions truthfully and have not withheld any relevant information. I/We certify that any answers not in our own handwriting have been checked by me/us and are correct. I/We have read and understand the PDS and Policy Document and agree to be bound by all terms and conditions. I/We agree that the Proposal and Policy Schedule is the basis of the insurance contract. I/We agree to allow the administrator to obtain any relevant information from the financier or interested parties. Agent Name: POMI Agent No: RA00011 ISN: A01982 When the premium has been paid the Proposal & Policy Schedule may be used as a Tax Invoice. This Cover is underwritten by VIRGINIA SURETY COMPANY, INC $ 454.55 $ 45.45 $ 25.00 $ 0.00 $ 525.00 Payment Details Finance Credit Card Cash Other

Generated: 11/07/2013 at 04:52 PM

Doc ID: VSC EWI 0513/001

EXTENDED WARRANTY INSURANCE


Proposal & Policy Schedule
Please provide all Information requested and answer all questions fully to enable us to process your warranty. If there is insufficient space provided for any details please attach a separate sheet of paper. Agent Details Dealer Name POMI Dealer No. RA00011 Insured Details
First Insured Title First Name Last Name Address Postcode Home Phone Business Phone Mobile Phone Email Address Date of Birth ABN Registered for GST MR. JAMES A 14 ASNITA ZARA NEW SOUTH WALES 2484 1487878788 Second Insured Title First Name Last Name Address Postcode Home Phone Business Phone Mobile Phone Email Address Date of Birth ABN Registered for GST

Policy Number: 0003001221

ISN

A01982

01/01/1980 No

Corporate Details
Company Name Address Suburb State, Postcode Business Phone ABN Number Registered for GST

Vehicle Details
Make Model Compliance Year Reg No. ABARTH 500 CONVERTIBLE 2013 AS410 VIN Number Drive Type Odometer at purchase Vehicle Use 11/07/2013 11/07/2013 ESANDA - ANZ BANKING GROUP LIMITED A1401 12000 PRIVATE Body Type Cylinders Transmission Fuel Type 12 0 11/07/2013 CONVERTIBLE T4 5 SP AUTOMATED MANUA

Factory Warranty Start date Vehicle Purchase Date Financier (if financed) Vehicle Modifications

Factory Warranty Length (mths) Statutory Warranty Length (days) Date First Registered

Cover Term
Type of Cover Vehicle Use Dealer Service Waiver 12 Months PRIVATE NO EXTENDED WARRANTY SILVER Vehicle Class Period Of Insurance B From: 11/07/2014 To: 11/07/2015

Premium Details
Premium Details Net Premium GST on Premium Stamp Duty Establishment Fee Total Premium $ 454.55 $ 45.45 $ 25.00 $ 0.00 $ 525.00 Payment Details Finance Credit Card Cash Other Declaration by Insured Person(s) I/We the undersigned declare that; I/We have answered all questions truthfully and have not withheld any relevant information. I/We certify that any answers not in our own handwriting have been checked by me/us and are correct. I/We have read and understand the PDS and Policy Document and agree to be bound by all terms and conditions. I/We agree that the Proposal and Policy Schedule is the basis of the insurance contract. I/We agree to allow the administrator to obtain any relevant information from the financier or interested parties. Agent Name: POMI Agent No: RA00011 ISN: A01982 When the premium has been paid the Proposal & Policy Schedule may be used as a Tax Invoice. This Cover is underwritten by VIRGINIA SURETY COMPANY, INC

Generated: 11/07/2013 at 04:52 PM

Doc ID: VSC EWI 0513/001