Online Quote Request Insured’s Full Name * Insured’s Date of Birth * 2nd Insured’s Full Name 2nd Insured’s Date of Birth Registered Owner(s) * Address (Street) * Address (Suburb) * Address (Postcode) * E-Mail * Contact Phone Number * Vehicle Year * Vehicle Make (Ford, Holden, Toyota etc) * Vehicle Model (Falcon, Commodore, Camry etc) * Body type Sedan Coupe Hatchback Wagon Cabriolet Convertible Ute Registration Number * Colour * Purchase Price * 2WD or 4WD? 2 Wheel Drive 4 Wheel Drive Turbo? Yes No Petrol or Diesel? Petrol Diesel Transmission Type? Auto Manual Tiptronic Gearbox (5 speed, 6 speed etc) * Engine Size * Engine Number/VIN *
Security Standard Alarm Only Immobiliser Only Alarm & Immobiliser Other
Is the vehicle registered, roadworthy and free from damage (including hail damage)? Yes No
Vehicle Use Private Business Rural Trade Vehicle Registered As Private Business Primary Producer If used for business, does vehicle have signwriting? If so, what is value? Occupation (if not for Private use)? Where is vehicle kept overnight? Garage Carport Driveway Street Where is vehicle during the day? Home Carpark Street Suburb and postcode where vehicle is kept during the day * Vehicle Finance? No Finance Vehicle is Financed If vehicle is financed, please provide finance company & type of finance Do you have a No Claim Bonus (written confirmation required) Nil / 6 20% / 5 30% / 4 40% / 3 50% / 2 60% /1 Have you ever had any accidents or claims? Yes No Have you ever had any traffic offences? Yes No Ever had your Licence cancelled, suspended or endorsed? Yes No Have you ever had insurance refused or declined? Yes No Have you ever had any criminal convictions? Yes No
Do you want Excess Free Windscreen Cover? Yes (Extra premium applies) No Do you want to include No Claim Bonus Protection? Yes One at Fault Yes All at Fault No Do you want to include Hire Car after an Event? Yes (Extra premium applies) No Cover Required 3rd Party Property Damage 3rd Party Fire & Theft Comprehensive Market Value Comprehensive Agreed Value (extra premium) If 3rd Party Fire & Theft or Comprehensive Agreed Value selected, please include value required.
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