Vehicle Insurance
What would you like us to do? (our Scope of Service)
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Add a vehicle to my existing policy
Replace existing vehicle on my policy
Create a new vehicle policy
Policy Number
If known
What Vehicle will this replace? (Please include registration number)
Are you:
Selling the old vehicle on the same date as purchasing the new vehicle (or trading in), so we can remove the insurance for your old vehicle
Still waiting for your old vehicle to sell, so we won't cancel this until you can confirm it has sold
Name of person answering the questions
*
First Name
Last Name
Are you the registered owner of the vehicle?
*
Yes
No
Who is the registered owner?
e.g. another person, company, trust
Is the policy to be issued in the name of the registered owner?
Yes
No
Who should the policy be issued in the name of?
e.g. another person, company, trust
What is the registered owners date of birth?
DD/MM/YYYY
Postal Address
*
this needs to be house number, street, suburb, town, postcode
Address vehicle will be located if different from above
E-mail
Phone Number
-
Area Code
Phone Number
What date do you want cover effective from?
*
-
Day
-
Month
Year
Date Picker Icon
How do you want to pay your premiums?
Fortnightly
Monthly
Quarterly
Six-Monthly
Annually
Vehicle Details
Will there be any business use of the vehicle?
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Yes
No
What kind of business use?
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Professional (no stock carried) e.g. accountant, lawyer
Trades
Uber, taxi, delivery, courier
Courtesy car
Motor trade
Other
Please provide a further description of the business use of the vehicle
What will this vehicle be used for?
Main vehicle
Work vehicle
'School run' vehicle
Spare car
Children's car
Hobby vehicle
Part of a collection
Race car/car not registered
Vehicle under restoration
Other
What is the estimated market value of the vehicle currently?
*
Dollar value
What is the current market value of the vehicle, plus the value of all accessories, plus the value of any signwriting?
*
Dollar value
Does the above figure include or exclude GST?
*
incl GST
excl GST
Type of Cover
*
Please Select
Comprehensive
Third Party Fire & Theft
Third Party
Details -
Details
Registration Number
Year
Make
Model/Sub Model
Body Type
No. Of Doors
Engine Size
Transmission (Manual/Auto)
Is there an alarm?
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Yes
No
Is there an immobiliser?
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Yes
No
Was this fitted by the manufacturer before the vehicle was sold in New Zealand?
*
Yes
No
Unsure
What is the Alarm NZSA Star Rating?
1
2
3
4
5
If not rated, give details of the system:
Where is the vehicle kept at night?
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Locked garage
Driveway
Road side
Other
Under finance or lease?
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Yes
No
Please provide detail if under finance or lease
*
Name and address of financier
Does the vehicle have accessories with a total value over $1,000 or has it been modified?
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Yes
No
Modifications
Select any that apply
$ value incl GST
Mag wheels
Stereo
Entertainment system
Communication or navigation system
Child seats or restraints
Suspension modified or lowered
Engine modified
Body kit or paint work
Exhaust modified
Other
Please provide detail on any modifications, including price
Specify incl or excl GST
Does the vehicle have any accessories?
*
Yes
No
Accessories
Select any that apply
Child seats/restraints
Navigation system
Jump start kit
Entertainment system
Please provide detail on any accessories, including price
Specify incl or excl GST
Would you like to add any of the below optional benefits?
*
Yes/No
Excess-free windscreen and window replacement cover
Yes
No
Hire car after an event
Yes
No
Roadside assistance
Yes
No
Do you need some cover for a hire car if your vehicle was written off, stolen or damaged?
Yes
No
How many days would you like to have this cover for?
Number of days, e.g. 35 days
What is the daily dollar limit you would require to rent a replacement vehicle?
Dollar amount, e.g. $150 per day
Is the vehicle to be used regularly for journeys exceeding 100kms or operated for more than 10 hours per day?
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Yes
No
Please provide full details:
Will the vehicle carry any hazardous goods?
*
Yes
No
Please provide full details:
Is the vehicle used, or intended to be used, air-side at any airport?
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Yes
No
Please provide full details:
How many regular drivers of the vehicle will there be?
*
1
2
3
4
5>
Number of people who would regularly drive the vehicle, including yourself
Will anyone under 25 ever drive the vehicle?
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Yes
No
Do you want to exclude cover for drivers under the age of 25? (this will reduce premiums, but will mean any drivers under the age of 25 will have no cover)
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Yes
No
Do you want to restrict drivers of the vehicle(s) to two persons over the age of 25? (this will reduce premiums, but will mean drivers other than the main named drivers will have a higher excess)
*
Yes
No
Who drives the vehicle?
Main Driver
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Who drives the vehicle?
Main Driver
Other Driver
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Who drives the vehicle?
Main Driver
Driver 2
Driver 3
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Who drives the vehicle?
Main Driver
Other Driver 1
Other Driver 2
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Who drives the vehicle?
Main Driver
Driver 2
Driver 3
Driver 4
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Who drives the vehicle?
Main Driver
Driver 1
Driver 2
Driver 3
Driver 4
Full Name
DOB (DD/MM/YYYY)
Sex
Licence (Full, Restricted,Learners)
How long have you held your licence (years)?
Will the addition of this vehicle trigger change in the main or regular drivers of your other vehicles insured through us?
*
Yes
No
Base Excess
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500
600
850
1100
Driver Questions
Have you, or any regular driver of the vehicle:
In the past 5 years had more than 2 losses or in the past 2 years made claims totaling more than $2,500?
*
Yes
No
Please provide full details, including the date of the incident, and a brief description:
Have any mental or physical condition or impairment that could affect their ability to drive?
*
Yes
No
Please provide full details:
Ever had a driving license suspended, cancelled or any special conditions imposed?
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Yes
No
Please provide full details, including date, reason, and for how long:
Had 5 or more traffic tickets in the last 5 years?
*
Yes
No
Please provide detail, including date and type of ticket:
Had any insurance declined, cancelled, renewal refused, terms or conditions imposed, or a claim declined?
*
Yes
No
Please provide full details:
Been engaged in any criminal activity, or had any criminal convictions, acquittals, or have any criminal prosecutions pending?
*
Yes
No
Please provide full details:
Been aware of any damage from flooding, landslip or earthquake at any address relating to this policy?
*
Yes
No
Please provide full details:
Driver Questions
Do all drivers have current and correct classes of licence to drive the vehicle?
*
Yes
No
If no, please provide full detail regarding the driver and what kind of licence they hold:
Have any drivers had any motoring accidents, convictions, infringements or prosecutions in the past 5 years or ever had any criminal convictions?
*
Yes
No
The information sought by this question is subject to the rights set out in the Criminal Records (Clean Slate) Act 2004
Please provide full details:
Have you made any claims in the last 5 years?
*
Yes
No
Please provide full details:
Have any drivers had a driving license suspended or any special conditions imposed?
*
Yes
No
Please provide full details, including driver name, date of suspension/condition applied, length and reason:
Has any driver been charged with any breach of regulations relating to work time driving hours or log work rules?
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Yes
No
Please provide full details:
Declaration & Privacy Statement
Have you read, and understood the above declaration & privacy statements?
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Yes
No
Authorisation
Have you read, and understood the above authorisation statements?
*
Yes
No
Please
click here
to open our Scope of Service.
I acknowledge I have read, and understand the Scope of Service including the Adviser disclosure.
*
Yes
Additional notes or queries that may affect your insurance?
Is there anything else you would like assistance with? (we will contact you)
KiwiSaver
Homeloans
Life/Health Insurance
Domestic insurances - e.g. house, contents, boat, trailer, camper van
Business insurances
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