subject_line
Cover type
*
Comprehensive
Third Party Property Damage
Vehicle Specifics
Year of Manufacturer
Make
Model
Variant
🛈
Registration
Vehicle use
Private Use
On Road Professional Salesperson
Tradesperson
Does the vehicle have hail damage?
Yes
No
Is the Vehicle financed
Yes
No
Finance Company
Drivers
First Name
Last Name
*
Gender
Female
Male
Date of Birth of Oldest Insured
*
+
Year licence obtained
Number of criminal convictions in the past 3 years
1
2
3
4
5+
Claim in the last 5 years
Yes
No
Claim Details
Do you wish to Add Additional Driver to avoid additional excesses
Yes
No
Additional Drivers First Name Surname Date of Birth Gender Year licence obtained Number of criminal convictions in the past 3 years Has there been any claims and/or licence suspensions in the past 3 years?
*
Cover
Vehicle sum insured (excluding non-standard accessories and modifications)
Sum Insured Option
Agreed Value
Market Value
Agreed Value Cover Required
Motor Insurance Excess Option
250
300
400
500
600
700
800
900
1000
1200
1400
1600
1800
2000
2500
3000
3500
4000
4500
5000
10000
Include Cover Options
Hire car during repairs
Windscreen excess waiver
Do wish to include any of the following cover options?
Does the vehicle have any of the following?
Specialised Paint
Turbo / Supercharger
Nitro / Hydrogen Fuel
Roll Bar / Roll Cage / Racing Harness
Does the vehicle have any non-standard accessories that will be included within the cover?
Yes
No
Non Standard Accessories
Please supply a description of Non Standard Accessories to be Insured and the Sum Insured
Overnight parking address
Street
City
PostCode
Currently Insured
Yes
No
Current Insurer
Current Premium
Underwriting Acceptance Criteria
Is the vehicle either
• unregistered or have any existing damage (excluding minor scratches, wear and tear or hail damage) or
• used for
• Driver Education
• Racing or Sporting Events
• Courier or Delivery Services
• Or used as a
• Hire Car
• Courtesy Car
• Taxi or
• Removalist vehicle
Or
Have you been declined insurance in the past 12 months
Or
Has your license been suspended or resticted in the past 5 years?
Yes
No
Underwriters consideration & Comments (please provide details)
Declaration: I/WE HEREBY DECLARE AND WARRANT that the answers given above are in every respect true and correct, and that I/We have not withheld any information within My/Our knowledge likely to affect the decision of the Company as to My/Our eligibility for insurance. This request and declaration shall be the basis of the quote request.
*
Yes
No
Contact Info
Phone
*
Email
*
Best time to Call
Call Me Now
08:00-09:00
09:00-10:00
10:00-11:00
11:00-12:00
12:00-13:00
13:00-14:00
14:00-15:00
15:00-16:00
16:00-17:00
17:00-18:00
18:00-19:00
19:00-20:00
Additional Information