4WD Insurance Form

Client Details:

Contact Name:*

Contact Email:*

Contact Telephone Number:*

Registered owner of vehicle

Title*

Given Name(s):*

Family Name:*

Date of Birth:*

Postal Address:*

Company Name:

What State was licence obtained?*

Year Licence obtained excluding L's:*

Policy Details

Due Date:*

Garaging Address:*

Occupation:*

Annual Kilometres*

Holding Insurer:*

General Underwriting Questions:

1. Has the owner/director or officer of the business, or the business itself sustained more than 3 losses, or had losses totalling more than $5,000 in the last three years of those sections to be covered by this policy?*

Yes
No

Provide details:

2. During the past five years

(a) Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership, or liquidation?*

Yes
No

Provide details:

(b) Has any owner/director of the business or the business itself been convicted of a criminal offence?*

Yes
No

Provide details:

3. Has the owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?*

Yes
No

Provide Details:

Parked/garaged:*

Postcode:*

Vehicle Details

Vehicle Make/Model:*

Year of Manufacture:*

VIN Number:*

Registration Number:*

Anti Theft Device:*

NCB Rating:*

Number of years in current rating or NCB:*

Cover:*

Vehicle Value

Non Standard Accessories:*

Item Description	Year of Manufacture	Value ($)

Listed Driver Details:*

Title	Given Name(s)	Surname	Gender (M/F)	Date of Birth (dd/mm/yyyy)	Driver Type (Occasional or Regular)	Has the driver had any other prior claims in the last 5 years (Y/N)	Has this driver had their licence suspended, cancelled, or restricted in the last 5 years? (Y/N)

Have you answered yes (Y) in the previous question?*

Yes
No

Details of Incidents*

Please fill this in if you have answered yes above.

Driver Name (as above)	Date	Type of incident	Fine/Accident cost

Age of youngest driver:*

Underwriter Questions

Has any driver of the vehicle had their licence suspended or cancelled in the last five years?*

Yes
No

Has any driver of the vehicle had any convictions relating to alcohol drugs dangerous driving or failing to stop after an accident in the last five years?*

Yes
No

Has the vehicle been converted or modified by someone other than the manufacture?*

Yes
No

Do you require the Windscreen Excess Waiver Option?*

Yes
No

Do you require the Rental Vehicle Option?*

Yes
No

Is this vehicle in an unsafe, unroadworthy or damaged condition?*

Yes
No

Interested Parties

Is there any finance on the vehicle?*

Yes
No

Interested party type:

Interested party name:

Client Details:

Registered owner of vehicle

Policy Details

Vehicle Details

Vehicle Value

Underwriter Questions

Interested Parties

BRISBANE OFFICE