Motor Vehicle Quote Request

Please complete the questions below and click submit to receive your motor vehicle insurance quote

Name Name * First Last
Phone *
Email *
Company/Trade Name *
ABN *
Occupation *
Policy Information
What date do your require your policy to start from? What date do your require your policy to start from? * / DD / MM YYYY
Motor Vehicle Garaged Address Motor Vehicle Garaged Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
How is your Motor Vehicle kept overnight? *
Please select the level of cover you require *
Insured value *
If Agreed Value has been selected, please specify the insured amount
Vehicle Use *
KM radius from home base (for truck insurance only)
Optional Benefits, please tick if you want any of the following optional benefits included in your quote (if available)

Optional Benefits, please tick if you want any of the following optional benefits included in your quote (if available) Windscreen excess free Hire car after accident
Motor Vehicle Details
Registration Number *
Year *
Make (e.g Holden) *
Model (e.g Commodore) *
Series (e.g VX Series II) *
Transmission *
Body *
Fuel Type *
Body Type
Does your Motor Vehicle have any accessories or modifications? If yes, please provide the description and cost of each
Does the motor vehicle have any after market anti-theft security?
Is there finance on your Motor Vehicle? *
If select Secured Personal Loan, HP or Lease, please provide details;
Driver Details
Name - Driver 1 Name - Driver 1 * First Last
Licence Type *
Date of Birth Date of Birth * / DD / MM YYYY
Year Licence obtained *
Percentage (%) of use *
Name - Driver 2 Name - Driver 2 First Last
Licence Type
Date of Birth Date of Birth / DD / MM YYYY
Year Licence obtained
Percentage (%) of use
Current Insurer *
How many years claim free? *
In order to reduce your premium, are you willing to restrict the policy cover to drivers

In order to reduce your premium, are you willing to restrict the policy cover to drivers 25 years of age or over 30 years of age or over I do not wish to have any restriction with respect to driver’s age
Questions
During the past 5 years;

1. Have you had any motor vehicle insurance policies and or claims declined, cancelled or special terms imposed? *

During the past 5 years;

1. Have you had any motor vehicle insurance policies and or claims declined, cancelled or special terms imposed? Yes No
2. Have you been declared bankrupt? *

2. Have you been declared bankrupt? Yes No
3. Have you been convicted of a criminal offence, a DUI (driving under the influence), had your licence cancelled or suspended or been convicted of more than two traffic offences? *

3. Have you been convicted of a criminal offence, a DUI (driving under the influence), had your licence cancelled or suspended or been convicted of more than two traffic offences? Yes No
If yes to any of the above, please provide details; (dates/insurer/ description/cost of fines etc)
Have you had any motor vehicle accidents or claims, whether you were at fault or not? *

Have you had any motor vehicle accidents or claims, whether you were at fault or not? Yes No
if yes:
Date of Loss Date of Loss * / MM / DD YYYY
Claim Amount * $ Dollars . Cents
Driver Name *
Minimum of 2 characters required. Currently Entered: 0 characters.
Fault
Details *
Minimum of 10 characters required. Currently Entered: 0 characters.

Motor Vehicle Quote Request

Motor Vehicle Quote Request

Policy Information

Motor Vehicle Details

Driver Details

Questions

if yes: