Broker Acceptance

I/We do hereby appoint Shackleton Risk Management Pty (Ltd), a registered Financial Services Provider as my/our Insurance Brokers and Consultants. This agreement will incept from today’s date and will remain in force until cancelled by ourselves or by them in writing. We authorise you to act for and on my/our behalf as you may deem necessary.

I/We confirm that Shackleton Risk Management will be acting on my/our behalf and I/We hereby give Shackleton Risk Management permission to share personal information with Insurers and Administrators for the stated purpose only. It is acknowledged by us that it is necessary for Insurers and administrators to share information in order to assess and price policies fairly and to reduce the number of fraudulent claims submitted.

In view of the aforementioned, and on behalf of the company, I/We declare by submission and/or signing of this document to:

i. accept that it is in the public interest for insurers and administrators to share insurance information;

ii. consent to my policy and claims history being verified or shared with third parties in the ordinary course of business;

iii. accept that any information provided may be stored in a shared database;

iv. consent to such information being given to any other insurance company and/or reinsurance company or its agent should there be a legitimate business reason for doing so; and

v. accept that this information may where necessary be checked against other legal sources or databases