| Name: |
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| Date of Birth: |
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| Address or postcode where vehicle is kept: |
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| Phone number: |
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| Email address: |
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| Year, make, and model of vehicle: |
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| Series, cylinders, Transmission: |
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| Would you like to insure the vehicle for the agreed value or market value? |
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| Is Vehicle financed?If so, what type of finance?: |
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| No Claim Bonus/Rating Entitlement: |
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| Main driver's name? |
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| Main driver's Date of Birth? |
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| Date of birth of the youngest driver? |
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| What is the total cost of any non-standard modifications and/or accessories?: |
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| Are you a member of a 4WD club? If so, please include member number. |
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| Have you completed a 4WD driving course?: |
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| Would you like additional cover for the following?: |
| Lifetime Rating One Protection |
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| Windscreen Protection |
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| Low Kilometre Discount Option |
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| Camping Equipment Cover up to $3000 |
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| Is the vehicle kept in a garage overnight? |
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| Is an Immobiliser fitted to the vehicle? |
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| Have you or any of the other drivers (in the last 5 years): |
| Had a motor accident or loss, a vehicle burnt or stolen or made a claim under a motor insurance policy? (Regardless of who was at fault and regardless of whether an insurance claim was made for any loss). If yes, please include details. |
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| Received a speeding fine and/or been charged or fined for any motoring offence, or received an on-the-spot fine for a motoring offence (other than a parking infringement) including camera offences? If yes, please include details. |
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| Had or will have a driver's licence cancelled/suspended or special conditions imposed? If yes, please include details. |
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| Had a conviction for or been charged with driving under the influence of alcohol or drugs or any other criminal offence including theft, arson or fraud? If yes, please include details. |
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| Ever been declared bankrupt? If yes, please include details. |
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