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ABN: 12 162 702 025 | AFSL: 444494

Vehicle Quote

Your duty of disclosure

Before you enter an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984. If we ask you questions that are relevant to our decision whether to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. You have this duty until we agree to insure you.

If you do not tell us something

If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

By proceeding you confirm you have read and understood this duty

    Insurance type

    What type of insurance are you looking for?

    ComprehensiveThird Party Property Damage (TPPD)
    Note: This is not Compulsory Third Party Insurance (CTP)

    Start date

    When would you like your new insurance policy to start?

    Note: This must be within 30 days of today's date

    Where is your car usually parked overnight?

    Postcode

    Suburb/Town

    State

    Street number

    Street name

    Street type

    Where is your vehicle parked at night?

    Additional Information

    Approximately how many kilometres per year does your vehicle travel?

    What type of car do you want to insure?

    Year

    Car Manufacturer

    Model

    Body type

    Transmission

    Drive type

    Number of cylinders

    Fuel Type

    Additional accessories

    Has your vehicle had any modifications made to the engine, body/paint or suspension?

    Details of modifications

    Has your vehicle had any safety features added that are not standard?

    AlarmImmobiliserAll day tracking deviceMicrodotting

    Driver Details

    Date of birth

    Gender

    Age of the driver when they obtained their driver's licence?

    Is this driver the vehicle owner?

    Does the driver own another registered vehicle?

    Additional Information

    Is the vehicle financed?

    Who is your vehicle is financed by?

    Is your vehicle used for private, ride share or business use?

    Do you have a Comprehensive insurance policy for this or any other vehicle? (excludes Third Party and CTP)
    YesNo

    Who is your vehicle currently insured with?

    Has the driver within the past 5 years beem convicted of motoring offences (other than parking) or disqualified from driving?

    Please state the details

    Claim history

    Has this driver had any accidents/claims in the past 5 years?

    Year of Claim

    Description of Items claimed

    Value of Claim


    Did the driver drink any alcohol, or take any drugs or medication 12 hours prior to the accident?

    What did the driver drink or what drugs did the driver take?

    Quote contact details

    First name

    Mobile

    Email

    By providing your contact details, you agree that they can be used to contact you by email and / or phone to assist with this insurance quote and discuss your insurance needs.

    Declaration

    I/ We declare that the best of my/our knowledge and belief the information in this form is true and correct and I/we have not withheld any relevant information.

    I/we consent to the insurance company using my personal information I/we have provided on this form for the purpose of processing my quote. I/we understand that if I/we choose not to provide required details, this is my/our choice, however the insurance company may not be able to provide me with the requested quote.

    I/we consent to the insurance company disclosing my personal information to other insurers, an insurance reference services or as required by law. I/we consent to the insurance company also disclosing my personal information about me, from investigators or legal advisors.

    Please add your Digital Signature here

    Date

    Print Name

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