I declare that the above statements are true, that I have not suppressed or mis-stated any facts . 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 Action Insurance Brokers Pty Ltd, its Employees and Representatives 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”.