subject_line
Cover Type Requested
*
Caravan
Motorhome
Onsite Van
Relocatable Home & Park Home
Camper Trailer
5th Wheeler
Slide On
Horse Float
Box Trailer
Address Street
City
Postcode
*
Is the caravan street parked?
Yes
No
Cover Detail
Make
Model
Year of Manufacturer
🛈
Registration
Vin/Chassis Number
Purchase Price / Sum Insured
*
Date of Purchase
+
Length
Width
Construction
Brick or Stone
Concrete
Wood, Timber, Weatherboard
Is the home connected to mains water?
Yes
No
Is the property/van Owner Occupied / Tenanted
Owner Occupied
Tenanted
Lay up months?
🛈
Annexe Sum Insured
Details of Annex Construction
Content Sum Insured (in addition to the automatic $2,000 contents cover)
Lay Up Months:
🛈
January
February
March
April
May
June
July
August
September
October
November
December
Security
Windows have keyed Locks
*
Yes
No
Louvre Windows - Not Present or Barred
*
Yes
No
Windows have security Screens or Bars or Grills or Aluminium roller shutters
*
Yes
No
Windows have standard Locks
*
Yes
No
Doors have standard locks
*
Yes
No
Doors have double keyed deadlocks
*
Yes
No
Doors have single keyed deadlocks/security doors
*
Yes
No
Sliding Doors - Not Present or Patio Bolts
*
Yes
No
Alarm?
*
Yes
No
Your details
First Name
*
Last Name
*
Date of Birth
+
Currently Insured
Yes
No
Current Insurer
Caravan towing experience (in years):
Interested Party/ or Finance Company
Phone
*
Email
*
In the past 5 years have you had any claims?
*
Yes
No
Have you in the last 5 years had any insurance refused or cancelled?
Yes
No
Have you in the last 5 years ever had their motor vehicle or motorcycle license suspended or revoked for any reason?
Yes
No
Have you in the last 5 years been charged of convicted of any offence (other than caravan offences)?
Yes
No
Consideration & Comments
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
Ausure Insurance Brokers Pty Ltd T/as Insure 247 authorised representative of Ausure Pty Ltd AFSL 238433