Motor Vehicle Insurance
Proposal Form
Insured Persons
*
Rows
Applicant 1
Applicant 2
Full Name
Date of Birth
Contact Number
Email
Policy Start Date
Garaging Address
*
Street Address
Street Address Line 2
Town
State
Postcode
Mailing Address if different from garaging address
Street Address
Street Address Line 2
Town
State
Postcode
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PROPERTY DETAILS
Vehicle Details
*
Rows
Rego Number
Engine/Vin Number
Year
Make
Model
Engine Size
Petrol or Diesel
Manual or Auto Transmission
Cover Type
*
TPPD (Third Party Property Damage)
Comprehensive
Use
*
Private
Business
Vehicle Sum Insured
*
Market
Agreed
Agreed Value
Basic Excess
Security Devices
Under Finance
*
Yes
No
Financier
No Claims Bonus (Rating1=60%)
If Rating 1 (60%)– how many years?
Options
Windscreen
Hire Car
Protected NCB
Nominated Driver
Low Kilometers
Where is the vehicle parked at night?
Please Select
Garage
Carport
Street
Other
Where is the vehicle parked during the day?
Please Select
Home
Street
Secured Carpark
Unsecured Carpark
Other
Accessories
Examples: Window Tinting, Alloy Wheels, Spoiler, Tow Bar, Bull Bar, Signwriting
Modifications
Enhancements that affect the performance, safety, or change the characteristics of the vehicle beyond the manufacturer’s specification
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DECLARATIONS
Driver Details
*
Rows
Driver 1
Driver 2
Driver Name
Date of Birth
Year Licence Obtained
Gender
No of at fault incidents in the last 3 years
Has any insurer in respect of any insurance policy held by you ever:
*
Rows
Yes
No
Had an insurance policy cancelled, declined or terms imposed?
In the last 5 years have you had any convictions for driving under the influence of alcohol, drugs or had a licence, cancelled or suspended?
Have you been convicted of any criminal offence?
Have you had any claims in the past 5 Years?
Claims History
Rows
Driver
Date
Details
Insurer
Amount
Traffic Incident History: (Last 5 years) – Speeding, Driving Under the Influence, Loss of Licence etc.
Rows
Driver
Date
Details
Insurer
Amount
Submit
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