Commercial Motor Vehicle Insurance Quotation - ATIA Insurance Services Pty Ltd

Commercial Motor Vehicle Insurance Quotation Query
Thank you for your interest in having ATIA support you with insurance solutions for your business. The information you provide in this form may be used by ATIA to seek insurance quotes from various insurance providers. Please answer all the below questions completely and honestly. If any information provided is not correct it may jeopordise any resulting insurance cover including the potential that your risk is not insured.
Business name*
ABN
Contact name*

First NameLast Name
Email*
Phone*
Depot address*

Street Address

Street Address Line 2

SuburbState

Post Code
Insurance(s) required:*

Commercial Motor VehicleGoods In TransitPublic Liability
Commercial Motor Vehicle
Vehicle details
Do you need cover for a non-owned trailer?

YesNo
What limit do you require?
What is the body type of your light rigid vehicle(s)?
What is the body type of your heavy rigid vehicle(s)?
Do you require cover for downtime?

YesNo
Does your radius of work exceed 250km?

YesNo
Will there be anyone under the age of 25 driving the vehicle(s)?

YesNo
Will there be anyone driving the vehicle(s) who has held their truck licence for less the 2 years?

YesNo
Has anyone who will be driving the vehicle(s) had any driving infringements or had their licence suspended or cancelled in the last 5 years?

YesNo
Has anyone who will be driving the vehicle(s) had any criminal convictions in the last 5 years?

YesNo
Have you had any motor vehicle claims in the last 5 years?

YesNo
Claims history last 5 years
Goods in Transit
What type of goods do you carry?
Do you carry any refrigerated items?

YesNo
Do you carry any dangerous goods?

YesNo
What load limit do you require?
Public Liability
What is your estimated turnover?
What limit do you require?

$5 Million$10 Million$20 Million
Following completion of this form, an ATIA insurance executive will contact you to further discuss your insurance needs and to gather any additional information that may be required. Once we have all necessary information, we will seek insurance quotes with the view to provide you options within 2 business days of receiving complete information required by insurer(s).
Declaration
I/We:
1. approve the use of this information for the purpose of contacting me/us to discuss potential insurance solutions, obtain further risk information from you and if possible, arrange insurance,
2. agree to ATIA collecting, holding, using and disclosing personal information about me/us in accordance with ATIA’s Privacy Policy and website Terms of Use, and
3. understand that insurance and/or endorsements are not bound or finalised until such time as the insurer has confirmed acceptance of the proposed insurance and ATIA has advised me/us in writing.
Signature*

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Commercial Motor Vehicle Insurance Quotation Query

Commercial Motor Vehicle

Goods in Transit

Public Liability

Declaration

I/We: