Private 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
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.
Format: 0000000000.
Motor Vehicle Details
Year
Make
Model
Registration Number
Purchase Price
Date of Purchase
-
Day
-
Month
Year
Date
Transmission
Please Select
Automatic
Manual
Agreed Value
$
Market Value
$
Sum Insured (agreed value)
Windscreen Cover
Please Select
Yes
No
Hire Car Cover
Please Select
Yes
No
Rows
Accessories
Value
1
2
3
4
5
6
Rows
Modifications
Value
1
2
3
4
5
6
Excess
$
Extensions/Clauses
Please Select
Windscreen Protection
Hire Car Following Accident
Both
Driver Details
Driver #1
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Driver #2
Name
First Name
Last Name
Date
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
%
Driver #3
Name
First Name
Last Name
Date
-
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
Rows
Yes or No
Will any drivers under 25 years of age be driving the vehicle?
Yes
No
If yes, percentage of use?
Yes
No
If yes, do these drivers own their own vehicles?
Yes
No
Does the vehicle have any existing damage, defects (rust, hail or unrepaired body damage)?
Yes
No
Does the vehicle have any mechanical or other problems which will make it unsafe?
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 drivers ever had insurance cancelled, declined or special conditions imposed?
Yes
No
Has the insured or any drivers ever been declared bankrupt or been placed in receivership?
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
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
Print Form
Save
Submit
Should be Empty: