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Quote Form Personal Motor Vehicle (Obsolete)
Contact Details
Situation at Risk
Vehicle Details
Driver Details
Insurance History
Additional Information
Contact Details
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Contact Person:
Email Address:
Phone Number/Mobile:
Birth Date:
Insured Name:
Situation at Risk
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Vehicle Address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Vehicle Details
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Vehicle Details #1
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Variant, body type and transmission
Vehicle Registration
Who owns this vehicle?
Interested Parties
Yes
No
Interested Party Type
Please select
Bank/Financial Institution
Lessor
Other
Other Interested Party Type
Interested Party Name
Vehicle Use
Please select
Private
Business
Occupation / Business Activities
Is the vehicle unregistered or does it have any existing damage excluding minor scratches or wear and tear?
Yes
No
Details of damage or registration
Is the vehicle used for any of the following?
Driver education
Racing or sporting events
Courier or delivery services
Airside operations
Carrying passengers for hire, fare or reward
Is the vehicle used as a
Taxi
Fleet / pool vehicle
Hire car
Courtesy car
Removalist vehicle
If any of the above vehicle usages apply please provide details
Vehicle Address Type
Please select
Per Vehicle Address
Other Address
Overnight garaging address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Overnight parking type (garage/carport/driveway/street etc)
Anti-Theft Devices
Immobiliser
Data Dot
Alarm System
Tow Bar locking devices including padlock
Other
Other Anti-Theft Device/s
Cover Type
Please select
Comprehensive
Third Party, Fire and Theft
Third Party Liability Only
Basis of Settlement
Please select
Agreed Value
Market Value
Sum Insured excluding non standard accessories and modifications
List any non-standard accessories including their value
List any vehicle modifications including their value
Current Basic Excess
Windscreen Excess Waiver
Yes
No
Maximum No Claim Bonus Protection
Yes
No
Hire car following an at fault accident
Yes
No
+ Vehicle Details
Driver Details
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Driver Details #1
Driver Name
Date of Birth
Gender
Please select
Male
Female
How long have they held their driver's license for (excluding learners)?
Has this driver had any accidents or claims in the last 5 years?
Yes
No
List any claims in the last 5 years (date, description, cost and whether the claim or repairs are complete). Alternatively send us the claims history on your insurers letterhead.
Has this driver been convicted of or had any fine or penalties imposed for any driving related drug/alcohol offences in the last 5 years?
Yes
No
Has this driver had their driver's license cancelled, disqualified or suspended in the last 5 years?
Yes
No
If yes to any of the above questions please provide details or phone us to discuss the matter:
Which vehicle/s will this driver use?
+ Driver Details
Insurance History
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In the last 5 years have you
i) had insurance refused, cancelled, declined or special terms imposed?
Yes
No
ii) been declared bankrupt, placed in liquidation, receivership or voluntary administration?
Yes
No
iii) been convicted of or had any fines imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?
Yes
No
If yes to any of the above questions please provide details or phone us to discuss the matter:
In the last 5 years have you had any claims or losses for the type of risks to be insured?
Yes
No
List any claims in the last 5 years (date, description, cost and whether the claim or repairs are complete). Alternatively send us the claims history on your insurers letterhead.
Who is your current insurer?
What is your current premium?
Additional Information
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Submit
Please provide any additional information relevant to your risk, or additional covers you may require
Policy Effective Date
Policy Expiry Date
Would you like to pay monthly?
Yes
No
Promo Code