Motor Insurance Quote

Motor Insurance

No Obligation Quotation Form
Please answer all questions honestly
- This a request for a FREE no obligation insurance quotation only
- No insurance cover is active until a completed proposal form is received
- All quotations are processed by Qualified Insurance Brokers
- Once we receive your quotation request we will issue a quotation within 24 hours (weekdays)
If you need assistance please contact our office directly

Phone: (03) 9015 4588

Email: broker@nibrokers.com.au
Your Details

The registered Owner of the vehicle
Name*

First NameLast Name
Phone Number*
Best Contact Number
Email*
ineed@insurance.com
Policy Due Date*

DayMonthYear
Select today's date if this is a new policy
Vehicle Details

Tell us about your vehicle
Year
Make
Model
Registration Number*
Does the vehicle have any hail damage? *
What do you use the vehicle for?*
This policy option is NOT suitable for rideshare
Overnight Garaging Address*

Street Address

Address Line 2

CityState

Post Code
Policy Coverage
Required Coverage Type*
Please refer to description for coverage descriptions
Is the Vehicle is financed?
Note the name of the Bank, Finance Company
Would you like to include any of the following policy options?*
Does the vehicle have any Non-standard/Non-Genuine accessories that will be included in the cover?*
Please list any Non-standard/Non-Genuine accessories to be insured
Does the vehicle have any modifications that will be included in the cover?*
Please list any modifications to be insured
Driver Details

Please list all drivers who are to be insured under the policy
Main Driver

The regualr driver of this vehicle
Driver Details*

First NameLast Name
Driver Date of Birth*

DayMonthYear
Date
Year license obtained
Excluding Learners Permit
Additional Driver

List any other driver who could drive this vehicle
Driver Details

First NameLast Name
Driver Date of Birth

DayMonthYear
Date
Year license obtained
Excluding Learners Permit
Claims

This question applies to ALL drivers of your vehicle
Has there been any claims made and/or licence suspensions in the past 5 years (to be answered for all drivers to be covered under the policy)*
Driver Name

First NameLast Name
Date of Claim or Licence Suspension/Cancellation

DayMonthYear
Date
Type of claim/driving conviction
Value of Claim (if known)
Do you require cover for learner drivers?*
APPLY CODE
Enter your promotional code
Comments
Provide any additional information here
Upload any Documents here

Upload Files
OPTIONAL: You can upload your current policy or claim history here Cancelof
If you do not understand the content of this Important Notice,please contact us immediately.

If any of the statements in this Application form are untrue, and you have suppressed or mis-stated any facts and/or should any information given by you alter between the date of this Application form and the inception date of the insurance to which this Application form relates, you must immediately notify us.

You authorise us to collect or disclose any personal information relating to this insurance to any insurer or insurance reference service. Where you have provided information about another individual (for example, a relative, employee or client), you have or you will make the individual aware of that fact and the section in the Policy on "The way we handle your personal information".

You agree that you have read and understood this notice by doing any of the following:
- Signing and returning a copy of this form; or
- Providing the information requested and returning the form to us; or
- Providing us with instructions to place the policy
- Consent to receiving a phone call or email from us to provide you with an indicative quote. We may also call you about our other products and services, you can opt out of this when we contact you or by calling us on 03 9015 4588
Signature*

Clear
Date

DayMonthYear
Date this form was completed
About Us

Contact Details

03 90154588

broker@nibrokers.com.au

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The information contained within this form including links is general and is not intended to serve as advice. It does not take into account the objectives, financial situation or needs of any particular person. For qualified advice please contact our office.
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Motor Insurance

Your Details

Vehicle Details

Policy Coverage

Driver Details

Main Driver

Additional Driver

Claims