Motor Vehicle Insurance

Make

Model / Type / Series: (e.g. Commodore Executive VX)

Year

Body type

Engine capacity in litres

Transmission

Metallic Paint

Accessories / modifications (please give details and value)

Estimated value of vehicle($)

Suburb in which the vehicle will be parked at night

How will it be parked

Suburb in which the vehicle will be parked during the day

How often is the car used

Approximate distance traveled per year (km)

What purposes is the vehicle mainly used for

What is the ownership status of the vehicle

Do you have any car club memberships? (give details)

Does the vehicle have any anti-theft equipment?

If yes, please specify:

Other

Age of regular driver

Regular Driver Gender

Percentage of use(%)

How long has this driver held a drivers license?

Details of any traffic offenses, accidents, vehicles stolen, any other vehicle loss/damage and license suspension or cancellation for the last 5 years

Are you entitled to a No Claim Bonus?

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)

Age of other driver 1

Other Driver 1 Gender

Percentage of use Other Driver 1 (%)

Age of other driver 2

Other Driver 2 Gender

Percentage of use Other Driver 2 (%)

Previous insurer

Due date of policy

Amount Paid($)

Any other notes you wish to include

Your Full Name

Daytime Phone Number

Your Email Address

Your Fax Number

Your Postal Address