Vehicle Details
What type of policy is required?
Comprehensive Agreed Value
Comprehensive Market Value
Third Party Property Damage
Third Party Fire & Theft
How is the vehicle registered?
Private use only
Business use only
Registered business/used private
Private/occassional business
Where is the vehicle parked during the day?
Garage/Security Parking
Driveway/Street
Private Parking Lot
Public Parking Lot
Railway Station
Shopping
None
Where is the vehicle parked at night?
Garage/Security Parking
Carport
Driveway
Parking Lot
Street
What type of finance do you have on the vehicle?
Not Financed
Hire Purchase
Corporate Hire Purchase
Bill of Sale
Chattel Mortgage
Lease
Finance Company Secured
Bank Loan Secured
Credit Union Secured
Unsecured Finance
Personal Loan
What is the annual distance travelled?
Up to 5,000km
5,000 to 7,000km
7,000 to 10,000km
10,000 to 15,000km
15,000 to 25,000km
25,000 to 30,000km
30,000 to 40,000km
40,000 and more
Does the vehicle carry goods?
Yes
No
Vehicle colour?
Unknown
Black
Blue
Brown
Burgundy
Charcoal
Cream
Green
Gold
Orange
Pink
Purple
Red
Silver
White
Yellow
Main Driver Details
What is the gender of the main driver?
Male
Female
How many no claim bonus years are held by the driver?
0
1
2
3
4
5
6 or more
Additional Drivers
Note: "% Driven" is the percentage of time the additional driver drives the vehicle.
Additional Driver One
What is the gender of additional driver one?
Male
Female
How many no claim bonus years are held by the driver?
0
1
2
3
4
5
6 or more
Does the driver own their own vehicle?
Yes
No
Additional Driver Two
What is the gender of additional driver two?
Male
Female
How many no claim bonus years are held by the driver?
0
1
2
3
4
5
6 or more
Does the driver own their own vehicle?
Yes
No
Additional Driver Three
What is the gender of additional driver three?
Male
Female
How many no claim bonus years are held by the driver?
0
1
2
3
4
5
6 or more
Does the driver own their own vehicle?
Yes
No
Cover Options
What is your preferred excess option?
$0
$100
$250
$500
Standard
(Note: Your preference may not be available for all policies.)
Do you want to remove the excess for windscreen claims?
Yes
No
(Note: This option may not be available for all policies.)
Do you want to protect your No Claim Bonus against at-fault claims?
Yes
No
(Note: This option may not be available for all policies and may only be available if you have held a No Claim Bonus for the minimum period required by the Insurer.)
Do you want to nominate or restrict any additional drivers?
Yes
No
(Note: This option may not be available for all policies.)
Do you want to take out a 'Hire Car after Accident' extension?
Yes
No
How Should We Contact You?
Title
Mr
Mrs
Ms
Miss
Preferred Contact Time
8am-12pm today
12pm-5pm today
5pm-8pm tonight
8am-12pm tomorrow
12pm-5pm tomorrow
5pm-8pm tomorrow night
Other (please specify in the comments below)
Preferred Contact Method
Email
Phone
