Farm Motor Vehicle 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
ABN
Registered for GST
Please Select
Yes
No
Occupation
ITC %
Type of Finance
Please Select
Personal Loan
Lease
Credit Union
Other
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.
Motor Vehicle Details
Year
Make
Model
Engine Number
VIN Number
Registration Number
Purchase Price
Date of Purchase
-
Day
-
Month
Year
Date
Transmission
Please Select
Automatic
Manual
Sum Insured (agreed value)
$
Sum Insured (market value)
Fuel Type
Please Select
Petrol
Diesel
LPG
Is the vehicle value inclusive of GST?
Please Select
Yes
No
Vehicle Class
Please Select
Private
Trailers luggage/boat/box/horse
Goods carrying up to
Vehicles > 2t < 5t
Vehicles > 5t < 10t
Vehicles > 10t
Non Articulated Trailers
Articulated Trailers
Motorised Machinery
Tractors
Trail Bikes
3 & 4 Wheelers
Type of Cover
Please Select
Comprehensive
Fire/Theft & Third Party
Third Party Only
No Claim Bonus Rating
%
Cylinders
Please Select
4 Cylinders
6 Cylinders
8 Cylinders
Accessories
$
Modifications
$
How will the machine be used?
Driver Details
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #3
Amount
Duty of Disclosure
Yes or No
Does the vehicle have Australian compliance plates and comply with Australian design rules regarding safety and emission control?
Yes
No
Is the vehicle maintained in a roadworthy condition, in working order, free from mechanical defects and in an undamaged condition?
Yes
No
Has any person who will drive any of the vehicles had any convictions for driving under the influence of alcohol, drugs, or had a licence cancelled or suspended in the last 5 years?
Yes
No
Has the insured or any person who will normally drive the vehicle been convicted of any criminal offences during the last 5 years or have any charges currently pending?
Yes
No
Has the insured or any person normally driving the vehicle had any claim declined or insurance refused or cancelled or special conditions imposed?
Yes
No
Does the vehicle have any existing damage, defects (rust, hail or unrepaired body damage)?
Yes
No
Do any of the drivers (who drive more than 10% of the time) have less than 2 years driving experience?
Yes
No
Is the vehicle fitted with a security device? (e.g. alarm system, engine mobiliser, tracking system)
Yes
No
a) Standard
Yes
No
b) After factory
Yes
No
Has the insured or any drivers ever been declared bankrupt or been placed in receivership?
Yes
No
Has the insured or any driver of the vehicle had their licence cancelled, suspended or endorsed?
Yes
No
Are there any exceptional circumstances relating to the risk to be insured that may affect the Insurer’s decision to accept the insurance?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
Print Form
Submit
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