We may collect personal information for the purpose of evaluating your insurance requirements and deciding whether to issue insurance cover and if so on what terms. Failure to provide any personal information requested may result in your application for insurance being declined. The information is collected and held by Vero Insurance New Zealand Ltd, 48 Shortland Street, Auckland. Individuals have a right to request access to and correction of their personal information under the Privacy Act. 1993. This form is transmitted to Vero CIS via email and may not be secure. If you have security concerns, please print off this form and either freefone 0800 505 905, fax to us +64 9 356 4606 or email to us at cissales@vero.co.nz or post to FREEPOST PO Box 1992, Auckland, 1140.