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: *
Cumberland FordCumberland Suzuki
YesNo
0 Days1 - 2 Days2 - 3 Days3 - 4 Days5 + DaysI don't work or study
Custom or specialised paint (aftermarket)Nitro or Hydrogen FuelPetrol Turbo or Supercharger (fitted/aftermarket)Roll bar/roll cage/racing harness
YesNo
YesNo
Less than 5,000Up to 10,000Up to 15,000Up to 20,000More than 20,000
Private UseBusiness UseRidesharing
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?
$795$895$995$1,195$1,395$1,695
Market ValueAgreed ValueUnsure
AnnuallyMonthlyI'd like to see both optionsUnsure
YesNoUnsure
YesNoUnsure
YesNoUnsure
YesNoUnsure
YesNo
YesNo
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: