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Apply Now

Apply now online or click here to download an Application Form and post today to:
Petsecure Pty Ltd
Locked Bag 9021
Castle Hill NSW 1765

* Denotes mandatory field

Personal Details: Title:
Other:
First Name:
Surname:
Address 1:
Address 2:
Suburb:
State:
Postcode:
Your Date of Birth:

Telephone - Home:
Telephone - Work:
Telephone - Mobile:
* Your email address:
Are you a pensioner?:
Name of Vet Practice:
Vet's Tel Number:
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How did you hear
about us?:

First Pet Details Pet Name :
Type :
Breed - Dogs:
Breed - Cats:
Sex :
Colour :
Desexed :
Date of Birth:

or Age of Pet :
Help

Assistance Dog :
Help

Doggie Rescue Mbr :
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Condition Details :
Microchip Number
(if applicable) :
Date of Last Vaccination :

Plan Type :
Per-Condition-Excess :
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Optional Wellness Care :

Second Pet Details: Pet Name :
Type :
Breed - Dogs:
Breed - Cats:
Sex :
Colour :
Desexed :
Date of Birth:

or Age of Pet :
Help

Assistance Dog :
Help

Doggie Rescue Mbr
Help

Condition Details :
Microchip Number
(if applicable) :
Date of Last Vaccination :

Plan Type :
Per-Condition-Excess :
Help

Optional Wellness Care :

Payment Details: Choose your Payment Frequency:

Choose your Payment Method by completing either the credit card or direct debit portions below:

Credit Card Details:
Cardholders Name:
Card Number:
Expiry Date eg 0608:

Direct Debit Details:

Bank/Financial Institution:
Branch Location/Suburb:
BSB:
Account Number:
Type of Account:

Authorisation:

By ticking this box I/We authorise The Hollard Insurance Company Pty Ltd (user ID 0686616) to debit funds from my/our account at the financial institution identified above and as prescribed by the Bulk Electronic Clearing Sydney (BECS).
I/We further advise the following:

The debit user to verify the details of the account with my/our financial institution
The financial institution to release information allowing the Debit user to verify the account details above.

Cooling-Off Period:

I understand that if I am not satisfied with the policy, I may return the policy documents within 14 days and any paid premium will be refunded. You cannot use this right where, before the 14 day period ends you have exercised any of your rights or powers under this policy (eg. you have made a claim)Your 1st premium will be collected on the date your application is accepted with the understanding that it will be refunded should you exercise your cancellation rights within the cooling-off period.

Your Duty of Disclosure:

I declare that the answers provided in this application are true and I have not withheld any requested information. I acknowledge that if I fail to comply with my duty of disclosure, the insurer may be entitled to reduce their liability under the contract in respect of a claim, or may cancel the contract.

Authority to contact your Vet:

I Authorise any veterinary surgeon who has treated my pet to provide the insurer with any details regarding my pets health they may require.

Cancellation:

In the event that you cancel your policy after making a claim under the policy, Petsecure reserves the right to recover any unpaid balance of the annual premium immediately upon receipt of your cancellation notice, from your nominated bank / credit card account, notwithstanding the fact that you may have elected to pay your premiums by instalments.

Policy Disclosure Statement:

By submitting an application for Petsecure Pet Insurance, I acknowledge that I have electronically received (by printing or downloading) the PDS and FSG and have or will consider them. I have not received any advice and no analysis of my needs has been conducted.