Blacktown | Insurance Quote Request Form

Insurance Quote Request Form

To receive an accurate quotation please complete all fields in the form below. If you are unsure of answers to any questions, please leave them blank or answer with "unsure".
Main Driver Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Main Driver Date of Birth
On weekdays, where is your car usually parked during the day? List Suburb(s):
Address where your car is usually kept overnight:
Select the department you purchased your car:
Is the car driven three or more weekdays, on average, between the following peak times? 7:30am-9:30am and/or 3pm-6:30pm?*
How many days a week on average is the car used for trips to work or study?
Does the car have any of the following accessories or modifications?
Is your car financed?
Did you buy the car within the last 13 months as a new or ex-demo vehicle from a licenced motor dealer?
How many kilometers do you drive on average per year?
Please select what your car is used for primarily:
In the last 3 years how many car related claims, driver licence suspensions, cancellations, disqualifications or restrictions has the main driver had?
Who is your current or most recent car insurer?
Additional drivers - Please list everyone (except learner drivers) who will drive this car more than once during the period of insurance, whether that's regularly or only occasionally:
Date of Birth of Additional Driver
In the last 3 years how many car related claims, driver licence suspensions, cancellations, disqualifications or restrictions has Additional Driver(s) had?
Choose your preferred excess (Note: Performance model excesses start at $1395 in NSW):
How would you like to cover your car?
Do you prefer to pay annually or monthly?
Do you require optional Roadside Assistance?
Do you require optional Windscreen and Window Glass Cover?
Do you require optional Hire Car Cover after an event? (The business manager will explain hire car options (21 days or unlimited)).
New/Demo Cars only: Do you require optional Lifetime New for Old Car Replacement Cover?
In the last 3 years, have you or anyone to be insured under this policy had any insurance declined or cancelled, renewal declined, special terms imposed or had a claim refused?
In the 3 years, have you or anyone to be insured under this policy committed a criminal act in relation to fraud, theft, burglary, drugs, arson, criminal, malicious or wilful damage?
Please note your answers will be used for the insurer to decide if they can insure you and on what terms.

You have a duty to them under the Insurance Contracts Act to take reasonable care not to make a misrepresentation. To make sure that you meet this duty, it is important that you answer all questions truthfully and accurately.

If you give information that is not true and accurate, they may be able to reduce or refuse to pay a claim or cancel your policy, or both. If your failure is fraudulent, they may be able to refuse to pay a claim and treat the contract as if it never existed.
Should be Empty: