Motor Vehicle Quote Request Form
If you need any assistance with completing this form, please call us on 07 3709 8888
Insured Name:
*
Is this the Registered Owner of the Vehicle
*
Yes
No
ABN:
If registered in your business name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email:
*
example@example.com
Phone Number:
*
Start Date of Insurance:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
When do you need the policy to start?
End Date of Insurance
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
When will the policy end?
Are you currently insured?
*
Yes
No
If Yes, Please provide the name of your insurer and the your due date?
*
If uninsured please note n/a
Please advise your current premium?
*
$$
Please advise your requested excess?
*
Insurance History:
*
Rows
Yes
No
Proposal or Renewal Declined or special terms imposed?
Charged or convicted of a criminal offence in the last 5 years?
Any claims in the last 5 years?
Fines, Penalties or loss of license?
Have you ever been declared bankrupt?
Details if Yes to any of the above:
Single Vehicle
Details of the vehicle to be insured
Registration Number:
*
Vin/Engine Number:
*
Year:
*
Make
*
Model:
*
Series:
*
Insurance Type:
*
Comprehensive
TTP/Fire & Theft
Third Party Protected
Body Type:
*
Please Select
Sedan
Hatch
Utility
Wagon
Van
Coupe
Other
If Other please state the body type:
Transmission:
*
Automatic
Manual
Carrying Capacity: (Goods Carrying Vehicles Only)
Less than 2 tonnes
More than 2 tonnes
Non Standard Modifications:
Performance Enhancing or More Attraction to thieves including but not limited to Mag Wheels, Special Paint, Bodykits and Special Stereos
Non Standard Accessories:
Optional Extras from Dealer not factory fitted. For example Window Tinting, Alloy Wheels, Tow Bar, Weather Shields, Bug Guards
Registered:
*
Private
Business
Primary Producer
Purpose of Use:
*
Private
On Road Professional/Salesperson
Tradesperson
Where is it garaged?
*
Please Select
Driveway
Locked Garage
Street
Security Parking
Carport
Other
If Other, please state where:
Garaged Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Registered Name:
*
Must be Insured Name
Estimated Current Value:
*
Type of Policy:
*
Market Value
Agreed Value
Financed/Interested Party:
*
Yes
No
Name of Bank:
If Yes to Financed/Interested Party
Security:
*
Please Select
Standard
Alarm
Tracking System
Immobilizer
Steering Lock
Optional Extensions:
No Claims Bonus Protection
Hire Car following accident or theft (some companies only offer following theft)
Windscreen Extension (One excess free windscreen claim)
Driver Details:
*
Rows
Driver 1
Driver 2
Name:
Date of Birth:
Years Licensed:
No Claims Bonus:
Male or Female:
Accidents: (Y/N)
Convictions: (Y/N)
License Suspended or Cancelled: (Y/N)
Claims: (Last 5 Years)
Do you have any drivers under 25?
*
Yes
No
If you have multiple vehicles or additional insurances policies you would like us to quote on, please provide your most recent copy of these below:
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