ASR Application - Taxicare

Taxicare Member's Application and Declaration form
Applicant Details
Vehicle Owner Name*
Address*
Suburb*
State*
Postcode*
Operator Name (if different)
Contact No.*
Email
Company/Business name (if applicable)
Address (if applicable)
ABN
Taxi Vehicle Details
Registration No.*
Year of Vehicle*
Vehicle Make*
Vehicle Model*
VIN / Engine No.
Is the car financed, If YES, by whom?
How many years have you been driving taxis?
How many years have you owned a taxi?
Applicants Declaration

We/I agree to abide by guidelines of Taxicare Australia’s Product Disclosure Statement.

We/I understand that the benefits and covers offered under this agreement are at the Board’s discretion and are contingent upon the truthfulness of this declaration and accordingly. We/I have not withheld any information that may affect the acceptance of this application or be regarded as reckless or unacceptable to the taxi industry.
Date cover is to commence*
DD slash MM slash YYYY
Applicant’s Name*
Applicant’s Signature*
(Draw your signature above)
Dated*
DD slash MM slash YYYY

Become a Taxicare member

Registration Number	Registered State	Vehicle Details