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Home
About Us
About Us
Why have Insurance?
Why use an Insurance Broker
Understanding Risk
Farm
Farm
Farm Motor
Crop
Livestock
Livestock Training
Theft of Livestock
Business
Business
Business Interruption
Office
Retail
Trades
Manufacturing
Cyber Insurance
Workers Compensation
Personal
Home
Contents
Landlords
Car
Residential Strata
Caravan
Travel
Pleasure Craft
Specialty
Farm Tender
Professional Indemnity
Liability
Construction
Marine Transit
Transport & Logistics
Sports
Medical Malpractice
Claims
Claims Notification
Emergency Contacts
Contact
Motor Vehicle Quote
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Motor Vehicle Quote
Motor Vehicle Quote
InsuraAdmin
2016-05-26T23:40:04+10:00
Insured Details
Registered Owner:
Date of birth:
Email:
Contact Phone Number:
Gender:
Male
Female
Year license obtained (excluding ‘L’s):
License state of issue:
Select State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Number of at fault incidents in the last 5 years:
In the last 5 years have you had any convictions for driving under the
influence of alcohol, drugs or had a licence cancelled or suspended?:
No
Yes
Claim Details
Cover Details
Cover type
Select…
Comprehensive
Fire Theft & Third Party Property Damage
Third Party Property Damage Only
Basis of settlement
Select…
Market Value
Agreed Value
Windscreen extension
No
Yes
Voluntary excess
Select…
$300
$400
$500
$600
$700
$800
$900
$1000
$1100
$1200
$1350
$1550
$2050
No claim bonus
Select…
1-60%
2-50%
3-40%
4-30%
5-20%
6-0%
7-0%
8-0%
Current Insurer:
Vehicle Details
Year
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
Make
Model
Transmission
Automatic
Manual
Colour
Vehicle Use
Private
Business
Private & Business
Vehicle Registration
Is the vehicle fitted with any non-standard or after market accessories
(excluding manufacturer optional accessories)
No
Yes
Description
Amount
Is the vehicle modified?
No
Yes
Description
Amount
Type of Security
Standard
Alarm system
Engine immobiliser
Tracking system – Car Watch
Tracking system – other
Transmission lock
Where is the vehicle usually parked overnight?
Select…
Garage
Carport
Driveway
Street
Other
City/Suburb/Town
State
Select State
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Where is the vehicle usually parked during the day?
At Home
Railway car park
Near Railway station
Security car park under cover
Security car park not cover
Covered car peark
Uncovered car park
Street
Other
Type of finance
None
Secured Bank Loan
Secured Credit Union/Building society Loan
Secured Finance Company Loan
Unsecured Personal Load
Nonvated lease
Other Lease
Hire Purchase
Bailee
Other
Finance/Lease Company details
Additional Vehicle Details
Is there any additional Vehicles?
No
Yes
How many additions Vehicles need to be added?
Vehicles Detail
Additional Drivers
Is there any additional drivers?
0
1
2
3
Drivers Detail
Attach photo
Select File(.pdf, .doc, .docx, .jpg, .jpeg, .png, .gif)
Note that all fields are mandatory and the form will not submit with empty selections.
Form may take several sections to send.
