Motor Quote Request - Fire and General Insurance

Tell us about Vehicle details.
Vehicle Year/Make/Model*
Accessories
Modifications
Transmission*
Type of Cover Requested*
- Comprehensive (Unlimited kms)
- Comprehensive ‘Limited Kilometres’ (Limited to 5,001-8,000 kms per year)
- Comprehensive ‘Low Kilometres’ (Limited to 0 – 5,000 kms per year)
Agreed Value*
If Purchased in Last 12 months
Purchase Price
Purchase Date
Date Format: DD slash MM slash YYYY
No Claim Bonus or Rating No*

1. Drivers less than 25 years of age not acceptable (30 in some cases).
2. Approved drivers must be licensed in Australia or New Zealand (provisional licenses excluded).
In the LAST THREE (3) YEARS have any of the drivers had any accidents, vehicles stolen or burnt, or any other losses involving a vehicle where an insurance claim has been made?*
- Yes
- No
Please provide details*
Driver Name Description of Loss Date of Loss Cost of Loss
In the LAST THREE (3) YEARS have any of the drivers committed any traffic offences which have resulted in a conviction or for which a penalty has been imposed or points lost?*
- Yes
- No
Please provide details:*
Driver Name Description of Offence Date Penalty Imposed If Speeding, kms over limit
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First Name	Last Name	% of Use	Date of Birth (dd/mm/yyy)

Driver Name	Description of Loss	Date of Loss	Cost of Loss

Driver Name	Description of Offence	Date	Penalty Imposed	If Speeding, kms over limit