Commercial Motor Enquiry

1
Personal Information* This field is required.
Your Name
Your Email
Your Number
2
Vehicle Details* This field is required.
Name of Registered Owner/s
Registration Number
Vehicle Year, Make & Model
Transmission Type & Carrying Capacity (GVM)
Please list details and value of any accessories, modifications and/or attachments. If NIL, please note N/A.
Is there finance on the vehicle? If Yes, please advise Financier
3
Vehicle Details* This field is required.
Full street address where vehicle is kept overnight.
Immobiliser
Immobiliser & Alarm
Alarm
No Security
Type of security device fitted.
Yes
No
Does the vehicle have any rust, hail or other unrepaired damage to the bodywork, paintwork or interior?
Yes
No
Does the vehicle have any mechanical or other problems which will make it unsafe?
4
Vehicle Details* This field is required.
What is your business occupation?
What is the vehicle used for? Please be as detailed as possible.
Comprehensive Market Value
Comprehensive Agreed Value
Cover Type
Sum Insured $
Yes
No
Do you require a quote for Hire Car Following an Accident?
5
Main Drivers Details* This field is required.
Drivers Full Name
DOB
Year Licence Obtained
6
Additional Drivers Details * This field is required.
Drivers #2: Full Name, DOB & Year License Obtained
Drivers #3: Full Name, DOB & Year License Obtained
Drivers #4: Full Name, DOB & Year License Obtained
Drivers #5: Full Name, DOB & Year License Obtained
7
Are there any drivers under 25 years old?* This field is required.
YESNO
8
In the last 3 years, has any person who is likely to drive the insured vehicle:* This field is required.
Option 1
Option 2
Option 3
Had any convictions or had any penalties imposed for driving under the influence of alcohol or drugs?
Option 1
Option 2
Option 3
Had a drivers licence cancelled or suspended or restricted?
Option 1
Option 2
Option 3
Been convicted or charged with any driving offences or issued any speeding or traffic infringements?
Option 1
Option 2
Option 3
Had any motor vehicle insurance refused?
9
In the last 3 years, has any person who is likely to driver the insured vehicle:* This field is required.
Option 1
Option 2
Option 3
Had any motor vehicle claims?
Option 1
Option 2
Option 3
Had any insurer decline a claim?
10
Have you ever or any partner(s) or director(s) of the business, ever had an insurance policy cancelled, declined or terms imposed?* This field is required.
YESNO
11
Have you ever or any partner(s) or director(s) of the business, ever been declared bankrupt?* This field is required.
YESNO
12
Have you ever or any partner(s) or director(s) of the business, ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. liquidation or receivership)?* This field is required.
YESNO
13
Have you ever or any partner(s) or director(s) of the business, ever been convicted of any criminal offence within the past 5 years?* This field is required.
YESNO
14
Have you ever or any partner(s) or director(s) of the business, ever been liability for any civil offence or pecuniary penalty (exceeding $5,000)?* This field is required.
YESNO
15
Is there anything else we should know?
Huge
Large
Normal
Small
Ok
Ok
Should be Empty: