Motor Vehicle Insurance Request Form
 Please provide brief details of the type of Motor Vehicle Insurance you require and we will contact you to complete our detailed analysis of the risk. Once we have issued our documentation to you and completed a risk review we will approach Insurer's on your behalf for terms. The completion or return of this form is not a confirmation or request for cover it is a means of contact to commence our review of your requirements. If you have an IMMEDIATE cover requirement please phone our office on 99297155 9-5pm weekdays. We welcome the opportunity to provide a quotation. Click for Location Map and Directions

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Name
Insured Name
Phone
E-Mail
Registered Owner
Finance/Interested Party

Status

Effective date cover is required:

Select Motor insurance policy type
(please select from list):

Policy options:

Would you like to pay extra to include one windscreen claim per year?:
(which doesn't affect your No Claim Bonus)
  Would you like to include No Claim Bonus Rating 1 Protection?:
( retain your NCB even if you have an accident which is your fault)
Would you like to exclude drivers under 25 from using this vehicle?
Would you like to restrict drivers to 2 named people only?

About the vehicle you wish to insure:
Make Of Vehicle:
Vehicle Model:
(e.g. Falcon, Camry, Commodore etc.)
Type Of Vehicle: (e.g. GL, GLX, etc.)
Colour: (e.g. White,Black,Silver etc.)
Year Vehicle Manufactured:
Body type (Sedan, Wagon etc.):
Engine capacity in litres:
Turbo:
Transmission: Manual     Automatic
4 Wheel Drive:
Accessories / modifications (please give details and value):
Estimated value of vehicle: $
Suburb Vehicle parked at night:  Postcode:
Where will it be parked?
Suburb Vehicle parked during the day:  Postcode:
Where will it be parked?
   
How often is the car used?:
Approximate distance travelled per year: kms
Purpose the vehicle is mainly used for?
Ownership status of the vehicle?


Security information about the vehicle:

Does the vehicle have any anti-theft equipment? Yes    No
If yes, please specify: Audible alarm only
Alarm & engine immobiliser (2 point)
Lock tight deadlocking
Steering lock
Mobile tracking
Self arming passive immobiliser (3 point)
Ignition kill switch
Other (please specify)  
 

Regular Driver Details:
Date of birth of regular driver:  M: F: Percentage of use: %
Name of regular driver:  
How long has this driver held a drivers licence? years
Have you had any traffic offences, accidents, vehicles stolen, any other vehicle loss/damage and licence suspension or cancellation for the last 5 years?                 Yes      No

If yes please give full details:

Are you entitled to a No Claim Bonus with your current insurer? Yes     No
If yes, please specify what rating:
If you hold rating 1, how many years has it been since your last claim
(enter 99 if you have never claimed):
 

Other Driver details:
Date of birth of other driver:  M: F: Percentage of use: %
Name of other driver:  
How long has this driver held a drivers licence? years
Have you had any traffic offences, accidents, vehicles stolen, any other vehicle loss/damage and licence suspension or cancellation for the last 5 years?                 Yes      No

If yes please give full details:

Are you entitled to a No Claim Bonus with your current insurer? Yes     No
If yes, please specify what rating:
If you hold rating 1, how many years has it been since your last claim
(enter 99 if you have never claimed):

Insurance history of the vehicle:
Your Current Insurer:           Your Policy Due Date:  


 

IMPORTANT: Please Read our General Advice Warning