(08) 6147 3200
ultra@uis.com.au
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Quote Form Personal Motor Vehicle
Contacts
Situation at Risk
Vehicle Details
Driver Details
Insurance History
Additional Information
Contacts
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Next
Name
Email
Phone number/mobile
Date of birth
Mailing 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
Are additional contacts required?
Yes
No
Additional Contacts
Additional Contacts #1
Name
Email
Phone number/mobile
Birth date
+ Additional Contacts
Situation at Risk
Previous
Next
Is your (primary contact person) home address the same as your mailing address?
Yes
No
Home address
(Cannot be a PO Box)
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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Next
Vehicle Details #1
Who owns this vehicle?
Vehicle usage
Please select
Private
Business
Vehicle Make
Vehicle Model
Vehicle Year
VIN / Chassis Number
Vehicle Registration
Body type
Please select
Sedan / Passenger Car
Hatchback
SUV
Ute
Sports
Wagon
Convertible
Station Wagon
Other / Let me describe
Describe body type
Transmission
Please select
Automatic / CVT
Manual
Dual-clutch
Semi-automatic
Type of cover
Please select
Comprehensive
Third Party, Fire, and Theft
Third Party Liability
Sum Insured (including fit out and equipment)
Motor vehicle cover details
Please select
Agreed Value
Market Value
Does the vehicle have any aftermarket accessories or modifications?
Yes
No
Please list aftermarket accessories or modifications and their value
Accessory/modification
Value
$
Describe any existing damage, excluding minor scratches or wear and tear
Will the vehicle be used for any of the following purposes: (select options that are applicable)
Driver education
Racing or sporting events
Courier or delivery services
Airside operations
Carrying passengers for hire, fare, or reward
Taxi services
Hire car services
Removalist work
Fleets or vehicle pools
Courtesy car
Where is the vehicle parked?
Please select
Garaged / Secure parking
Driveway / on the property
Carport
Street
Other
Describe parking arrangements
Is the parking/garage address same as the home address?
Yes
No
Vehicle parking/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
Anti-Theft Devices
Immobiliser
Data Dot
Alarm System
Tow Bar locking devices including padlock
Other
Other Anti-Theft Device/s
Sum insured (excl. non-standard accessories and modifications)
$
Current basic excess
$
Windscreen excess waiver
Yes
No
No claim bonus protection if available
Yes
No
Hire care after an accident
Yes
No
Nominated driver only
Yes
No
Is there an interested party (such as your bank)?
Yes
No
Interested Party Type
Please select
Bank/Financial Institution
Lessor
Other
Interested Party Name
+ Vehicle Details
Driver Details
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Next
Driver Details #1
Name
Date of birth
Gender
Please select
Male
Female
How many years has this driver held their driver's license for (excl. learners)?
Has this driver had any accidents or claims in the last 5 years?
Yes
No
List any claims from the last 5 years
Insurer
Claim date
Type of claim
Amount paid
At fault
Finalized
Description
Add/Remove Row
- Select -
Windscreen
Collision
Multiple Collision
Single Car Collision
Parked Damage
Theft
Storm
Other
$
- Select -
At Fault
Not At Fault
- Select -
Finalized
Not Finalized
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
Please provide details of the driving penalties, or alternatively phone us on (08) 6147 3200 to discuss further.
+ Driver Details
Insurance History
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Next
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, dishonestly, arson, theft, fraud, or violence against any person or property?
Yes
No
If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.
Additional Information
Previous
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
Who is your current insurer?
What is your current premium?
$
What is your current excess?
$
Promo code