Motor Vehicle Quotation
Please fill the form accurately for better assistance
Primary Driver
*
First Name
Last Name
Company Name & ABN
If vehicle is to be insured under a company
Registration Number
*
State of Registration
*
Please Select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Insured Value / Purchase Price
*
Make Model and Year
For eg: 2015 Mazda 3 SP25
Current odometer reading
*
For eg: 82001 km
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
For High Performance Vehicle Only
In the past 5 years does this proposed driver: Currently own, or had substantial experience in a vehicle similar* to that in this application?
If yes - please write the make and model of the vehicle. For eg: 2014 BMW M3 (2yrs)
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What is the address where the car is normally kept at night?
*
Same as residential address
Other
If "Other" please type the address below
Where is the car usually parked?
*
Carport
Off Street Parking
Garage
Driveway
Other
Type of Cover
*
Comprehensive
Third Party Property, Fire and Theft
Third Party Property Only
Any pre-exisitng damage on the vehicle?
*
Yes
No
How is the vehicle used?
*
Private
Private and Business both (less than 50% for business)
Business
How many kms do you drive in a year? (aprox)
for eg: 10,000
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Drivers Details
Date of Birth of the yongest driver
*
-
Day
-
Month
Year
Which year did you get your Australian licence? (do not include L's)
Your contact number
*
E-mail address
*
Claims History
*
In the last 5 years, how many claims have you made?
Interested Party
*
for eg: ANZ Bank
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Drivers Details
In the last 5 years have you or any other person named above had any drivers licence or permit cancelled, suspended or reduced to one of a lesser grade?
*
Yes
No
In the last 5 years have you or any other person named above made a claim on any motor insurance policy?
*
Yes
No
In the last 5 years have you or any other person named above suffered from any illness or disability likely to affect driving ability?
*
Yes
No
In the last 5 years have you or any other person named above had any claims refused, insurance policy declined, cancelled or had special terms imposed?
*
Yes
No
Have you been declared bankrupt and not discharged within the last 12 months, or currently involved in bankruptcy or repossession proceedings?
*
Yes
No
Have you in the last 10 years been convicted of, or had any fines or penalties imposed, for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?
*
Yes
No
In the last 5 years have you or any other person named above had any traffic offences, charges, infringements, convictions (excluding parking fines)?
*
Yes
No
Referred by (if applicable)
Submit
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