I/We, the undersigned claimant(s) hereby declare that the foregoing statements and particulars of the claim are true and correct and that I/We have not withheld any information relevant to this claim.
I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Fortitude Insurance Group in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.
The Privacy Act 1988 requires Fortitude Insurance Group to make the following disclosure before collecting personal information about you after 21 December 2001:
Simply contact the Fortitude Insurance Privacy Officer on the details below if you would like to: