Caravan Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Date of Birth
-
Day
-
Month
Year
Date
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Situation (if on site)
example@example.com
Postcode
example@example.com
Use of Caravan
Please Select
Private
On Site
Hire
Trade/Commercial
Type of Cover
Please Select
Australia Wide
On Site
No Claim Bonus/Rating:
Caravan Details
Year
Make
Model
Chassis No.
Registration No.
Length
Width
Date of Purchase
-
Day
-
Month
Year
Date
Purchase Price
$
Sum Insured
$
Annex Details
Year
Make
Model
Construction
Please Select
Canvas
Vinyl
Aluminium
Solid Walls
Purchase Price
$
Sum Insured
$
Contents Details
Legal Liability
Please Select
$2000000
$5000000
$10000000
$20000000
$30000000
Details
Fire Extinguishers
Please Select
None
Manual
Automatic
Fuel
Please Select
Diesel
Petrol
NA
Type of Use
Please Select
Private
Hire & Charter
Demonstration
Other
Type
Please Select
Classic
Off-road
Pop-top
Pop-out
Camper trailer & wind-up
Campervan
Motorhome
Fifth wheeler
Other
Storage
Please Select
Garaged
Storage
Other
Accessories Equipment
Max. Speed
Expiry Date
-
Day
-
Month
Year
Date
Contents Details
Automatic cover of $1,000. Would client like to insure a larger amount?
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Driver
Details of Claim #1
Amount
$
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Driver
Details of Claim #2
Amount
$
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Driver
Details of Claim #3
Amount
$
Duty of Disclosure
Rows
Yes or No
Does the caravan or annex have any existing damage or defects?
Yes
No
Has the caravan been modified or converted from the maker’s specification or fitted with accessories?
Yes
No
Has the insured ever been declared bankrupt or been placed in receivership?
Yes
No
Has the Insured or any drivers ever had insurance cancelled, declined or special conditions imposed?
Yes
No
Has the Insured or any drivers ever been charged or convicted of any criminal offence including drug use, driving under the influence or any driving offence, speeding infringements, fraud, arson or theft?
Yes
No
Has the insured or any driver of the vehicle had their licence cancelled, suspended or endorsed?
Yes
No
Does the Insured or drivers suffer from any physical or mental disability (excl. eyesight corrected by lens)?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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