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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 Maxton Insurance Brokers 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 our Privacy Policy (opens in new tab).