Certificate Cancellation/Variation Request form - Victorian Certificates

Victorian Residential Builders’ WarrantyCertificate Cancellation / Variation RequestSection 1 - Certificate informationBuilder NameReturn form/s and all suppporting documentation to:HIA Insurance Services Pty Ltd, GPO Box 4897 V V, Melbourne VIC 3001Phone: 1300 554 227 Fax: (03) 9654 3277Contact nameEmail AddressContact Phone NumberDomestic Builders Licence No Certificate / Policy Number Name of Insurer Aon Invoice NumberSite address State PostcodeSection 2 - Certificate CancellationCancellation of a certificate can only be made if the building contract has been terminated and no works have commenced on site, no monies are owing and,if a deposit has been paid, it has been refunded less all agreed costs. The following “VMIA APPLICATION TO CANCEL A CERTIFICATE OF INSURANCE” formmust be provided before a certificate/policy can be cancelled. Please note: On cancellation a refund cheque will be issued to the builder excluding the originalcertificate administration fee.Section 3 - Certificate Variations/AmendmentsChanges to the owners name/mailing addressFor changes to the owners name or mailing address (only) please call our office to discuss on (03) 9666 0222.Contract VariationsIf there is a variation to the contract exceeding the original contract price by 20% a copy of the building contract incorporating the variations must be provided.Please note an additional premium may be applicable.Change of Site Address, Contract Value or Contract DatePlease note the “VMIA Application to cancel a certificate of insurance” form, along with a newly completed “Job Specific Project Application” is requiredto be completed for change of site address, contract value or contract date. To minimise delays please ensure the owner also signs the “VMIAApplication to cancel a certificate of insurance” form.A change to the site address will require a copy of the contract and proof of the change of address eg. a copy of the annual council rates notice or the councilrates instalment notice. For any changes to the contract value (aside from variations) or the contract date, a copy of the contract is required. Please list thedetails of the requested changes below:Section 4 – Certificate Variation FeeCertificate Variations are subject to an Administration Fee of $82.50 (incl. GST), in addition to any additional premium charged by the Insurer. Paying by cheque: please makepayable to HIA Insurance Services. Paying by Credit Card: Please enter your credit card details in the section below. An Account Servicer will contact you to confirm the amountpayable and obtain authorisation to deduct the amount from your credit card. Credit card transactions will incur a surcharge of 1% for VISA and Mastercard and 2.75% for AMEX,which will be added at the time of payment processing.I authorise the fee / premium of$to be deducted from my nominated credit card.Credit Card TypeMastercard Visa AMEXCard NumberCCV NumberCard Expiry (mm/yyyy)Name on Card Signature Date27082013Section 5 - Certificate Typing ErrorsIf there is a typing error, please call our office to discuss on (03) 9666 0222.Page 1 of 1

APPLICATION TO CANCELA CERTIFICATE OF INSURANCEABOUT THIS FORMThis form is to be completed by the builder in situations where a Certificate of Insurancehas been issued by QBE/VMIA and the builder is seeking to cancel the Certificate of Insurance.This form MUST be signed by the DIRECTOR OR REGISTERD BUILDING PRACTIONER AND/OR OWNERnamed on the certificate. If not, the cancellation will not be approved.A B CPLEASE USECAPITAL LETTERS.SECTION A. DETAILS ABOUT THE CERTIFICATE OF INSURANCEBuilder name:Builder’s registration number:Policy number:Address of the domestic building worksUnit number/s: Lot number: Street number: Street name:Suburb/Town: State: Postcode:SECTION B. APPLICATION TO CANCEL A CERTIFICATE OF INSURANCE⚠ A certificate cancellation will only be considered if ALL of the following apply:The building contract has been terminated ✓ Nomonies are owing to any party to the contract✓No works have commenced on the siteIf deposit funds have been paid by an owner andnot returned, the Certificate of Insurance cannot be cancelled.There are no disputes between any parties to the contract

SECTION C. DECLARATION⚠This statutory declaration must be completed by EITHER the owner and/or builder named on the Certificate of Insurance.If not, the cancellation will not be approved.State of VictoriaSTATUTORY DECLARATIONI,[full name]of[address]1. The building contract has been terminated.2. No works have commenced on site.3. No monies are owing to any party to the contract.4. No disputes between any party to the contract., do solemnly and sincerely declare that:I acknowledge that this declaration is true and correct, and I make it with the understanding and belief that a person who makes a falsedeclaration is liable to the penalties of perjury.Declared at:Date:D D / M M / Y Y Y YSignature of person making this declaration:✎[to be signed in front of an authorised witness]Before me:✎Signature of Authorised WitnessThe authorised witness must print or stamp his or her name, address and title under section 107A of the Evidence (Miscellaneous Provisions) Act 1958 (as of 1January 2010), (previously Evidence Act 1958), (e.g. Justice of the Peace, Pharmacist, Police Officer, Court Registrar, Bank Manager, Medical Practitioner, Dentist)CERTIFICATE OF INSURANCE CANCELLATION Page 2 or 2