The following information is required so that we can provide an accurate insurance quote.

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Name *

First

Last

Phone *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Email *

Year of Manufacture: *

Make (e.g. Ford): *

Model (e.g. Mustang): *

Rego / Plate Number: *

Auto or Manual Transmission: *AutomaticManual

Accessories (eg Bull Bar, Tow Bar, Tinting): *

Please list vehicles accessories with indvidual values.

Vehicle value: *

What do you think your vehicle is worth? (i.e. Market Value).

Odometer Reading: *

What is your current odometer reading?

Annual kilometres: *

Approximately, how many kilometres is your vehicle driven annually?

Vehicle Use: *Private UseBusiness UseRegistered Business / Used PrivateMixed

Is you vehicle used for business or privates use?

Preferred Basic Excess: *$400$500$1000

What is you preferred basic excess for this quote.

Financed with: *

Who is your vehicle fiananced with?

Drivers Details: *

Please list the names and dates of birth of the main drivers?

Restricted Drivers: *Cover is needed for drivers under 25.No drivers under 25 will drive.

Previous claims, offences or convictions: *

Please advise any claims (last 5 years), driving offences or criminal convictions.

Other Information: *

Please advise other information that might be relevant, such as Garaging or Parking details, current insurance details, including policy expiry date.

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By clicking submit, you acknowledge that you have read and understood both the Duty of Disclosure and General Advice Warning as detailed below.

Duty of Disclosure: You and everyone who is insured under an insurance policy must comply with the duty of disclosure. You must provide complete and accurate information and instructions in a timely
manner, so that we can assist you fully. You have a duty to disclose to the insurer before a contract of insurance is entered into, upon any renewal or alteration / endorsement to the contract, every matter that is known to you that is relevant to the decision of the insurer whether to accept the risk. It is important that you tell us every matter that you know or that a reasonable person in your circumstances would know that would be relevant to an insurers decision whether or not to insure
you and on what terms. You must give honest and complete answers to each of the insurer’s
questions. You should disclose in answer to each question any matter that is known to you and
which a reasonable person in the circumstances could be expected to have told the insurer in the
circumstances. Failure to comply with your duty of disclosure may allow the insurer to avoid liability for a particular claim or to void the policy.

General Advice Warning (GAW): All the information provided may be regarded as general advice. That is, your personal objectives, needs or financial situations were not considered when preparing this information. Accordingly, you should consider the appropriateness of any general advice we have given you, having regard to your own objectives, financial situation and needs before acting on it. Where the information relates to a particular financial product, you should obtain and consider the relevant product disclosure statement (PDS) before making any decision to purchase that financial product.