Driver's Questionnaire
If any questions, please contact us at 1300 067873
1. INFORMATION
Name of Driver
Name of Insured (Company / Employer name if applicable)
Address
Contact phone number
Do you hold a current Australia drivers licence?
Yes
No
Licence No
Class of License
Total Years Licenced
Country (and State) of Issue
Birthday
-
Day
-
Month
Year
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2. IN THE LAST FIVE YEARS HAVE YOU
Had a Motor Vehicle Accident, or Vehicle Burnt, Damage or Stolen?
Yes
No
Made a Claim on a Motor Vehicle Insurance Policy?
Yes
No
IF YOU HAVE ANSWERED YES TO EITHER OF THE ABOVE, PLEASE PROVIDE FULL DETAILS OF ALL INCIDENTS INCLUDING DATE(S) OF INCIDENT(S):
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4. IN THE LAST FIVE YEARS HAVE YOU
Had an insurance application declined, policy cancelled, renewal refused or special conditions imposed by an insurance company?
Yes
No
Been fined, charged or convicted of any motoring or traffic offence (except parking)?
Yes
No
Had a driving licence endorsed, suspended or cancelled due to points accumulation?
Yes
No
Had a driving licence suspended or cancelled due to driving under the influence of alcohol or drugs?
Yes
No
Been charged or convicted of culpable, negligent or dangerous driving?
Yes
No
Been charged or convicted of driving whilst licence suspended or cancelled?
Yes
No
Been declared bankrupt?
Yes
No
Been charged or convicted of a criminal offence?
Yes
No
IF YOU HAVE ANSWERED YES TO EITHER OF THE ABOVE, PLEASE PROVIDE FULL DETAILS OF ALL INCIDENTS:
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4. INSURED DECLARATION
I/We hereby declare and warrant that I/We have read this questionnaire and that the answers given above are in every respect true and correct and that I/We have not withheld any material information.
Driver's Signature
Driver's Name
Date
-
Month
-
Day
Year
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Insured's Signature
Insured's Name
Date
-
Month
-
Day
Year
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Submit
Should be Empty: