Language
English (UK)
Motor Vehicle Insurance
Please add relevant details about the private motor vehicle you would like to insure into the form below. If you would like to insure more than one private vehicle, please fill out the form again for each vehicle after you have submitted your first application. One of our Expert Insurance Advisers will be in touch!
Personal Details
Full Name
*
First Name
Last Name
Date of Birth
/
Day
/
Month
Year
Address
Street Address
Street Address Line 2
Suburb
City
Postcode
Contact details
Home Phone
-
Mobile Phone
-
E-mail
*
Direct to client contact
Contact Adviser
ILG can share clients information with ML Adviser
Vehicle Details
Year
Make
Model
Registration Number
CC Rating
Declared Value
Parking
NCB
Purpose of use
Registered Owner
Turbo
Modification
Non Factory Accessories
Existing Damage
Alarm or Immobilizer
Existing Vehicle Insurance
Leave this section empty if the vehicle is not currently insured.
Current Insurer
Insurance Period From
Insurance Period To
Premium Payment
Driver Option
Type of Cover
Excess
Main Driver
Name
Date of Birth
-
Day
-
Month
Year
Driving Experience Overseas
Driving Experience in NZ
NZ Licence
Joint Driver
Name
Date of Birth
-
Day
-
Month
Year
Driving Experience Overseas
Driving Experience in NZ
NZ Licence
Accidents Claims History in NZ & Overseas
When / situation / claim amount / who was at fault / insurance company
Claim 1
Claim 2
Claim 3
Information
Any other information
Claim 3
Has any driver had a driver licence endorsed, suspended or cancelled?
Does any driver have a medical or physical impairment?
Convicted of a criminal or traffic offense, or had a traffic notice issued?
Please Run the Wizard
Should be Empty: