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Motor Vehicle Insurance Form
Please
contact
our office if you wish to insure 2 or more vehicles
General information
*Required
Legal Entity:
*
*
Indicates required field
Trading Name:
*
Name
*
First
Last
Phone Number
*
Email
*
Garaged Address:
*
Line 1
*
Line 2
*
State
*
Postcode
*
Country
*
Occupation:
*
Date of birth of youngest driver:
*
Date format: 01/01/0000
Vehicle
Year:
*
Registration:
*
Body Type (e.g. twin cab, cab chassis):
*
Manufacture & Model:
*
Number of Cylinders:
*
Use:
*
- Select -
Personal
Business
Transmission
*
- Select -
Automatic
Manual
Your No Claim Bonus - number of years with no claim:
*
5 years or more - 60% Rating 1 Protected
5 years or more - 60% Rating 1
4 years - 50% - Rating 2
3 years - 40% - Rating 3
2 years - 30% - Rating 4
1 year - 20% - Rating 5
0 year - 0% - Rating 6
Market Value or Agreed Value?
*
- Select -
Agreed
Market Value
Agreed value:
*
$
Do you require hire car benefit:
*
- Select -
Yes
No
Fuel Type:
*
- Select -
Diesel
Petrol
LPG
Security Device:
*
- Select -
Immobiliser
Alarm
Previous Insurance
Have you had any motor insurance in the past 12 months?:
*
Option 1
Option 2
Option 3
If Yes, please state name of insurance company:
*
Have you or any intended drivers, within the last 5 years, whether a claim was made or not;
had any motoring accidents?
*
- Select -
Yes
No
If you answered Yes to any of the above please provide full details :
*
Ability
Do you or any intended drivers suffer from defective vision or hearing or from any physical infirmity or fits of any kind?
*
- Select -
Yes
Np
If you answered Yes please provide full details:
*
Has any insurance company at any time, in respect of you or any other person to be covered under this policy or any person who may benefit from this insurance:
Had a proposal for insurance declined?
*
- Select -
Yes
No
Cancelled or refused to renew any policy?
*
- Select -
Yes
No
Required from you any increased premium?
*
- Select -
Yes
No
Ever withdrawn or declined a claim?
*
- Select -
Yes
No
Imposed any special conditions?
*
- Select -
Yes
No
If you answered Yes to any of the above please provide full details :
*
Have you or any intended drivers:
Been convicted or charged with any driving offence including speed camera or speeding fines or issued with any offence or infringement notice (other than parking) in the last 5 years?
*
- Select -
Yes
No
Had a license cancelled, suspended, endorsed or have been disqualified from driving in the last 5 years?
*
- Select -
Yes
No
Ever had any criminal conviction or have a pending prosecution for any criminal offence?
*
- Select -
Yes
No
If you answered Yes to any of the above please provide full details
*
Important Information
Your Duty of Disclosure
You must tell us everything you know (or could be reasonably expected to know) that a prudent insurer would want to take into account in deciding:
a) whether to accept your proposal and
b) if so, on what terms.
Examples of what you must tell us include:
a) anything that increases the risk of a claim
b) any criminal offending or convictions
c) any previous insurance claims
d) any refusal by another insurer to insure you on standard terms, or continue to insure you on standard terms.
You must also tell us this every time this policy renews, or when you make any changes to it. If you fail to do this, we may avoid the policy retrospectively. You will have no insurance at all. When in doubt, disclose. We treat all information confidentially.
Change of circumstances:
You must tell us of any material changes in your circumstances after the policy starts and during the policy period.
DECLARATION
This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We
a) declare that:
i. the answers and information given by me/us in this Application are true and correct in all respects;
ii. no information has been withheld that would affect an insurer's decision to accept this Application;
iii. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;
iv. I/we have read and understood the
Financial Services Guide
and
Privacy Statement
;
v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.
b) authorise National Insurance Group Pty Ltd to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Upload additional information or a copy of your current insurance here:
*
Max file size: 20MB
Please send all correspondence by email:
*
Yes
No, send by regular post
Signature:
*
Date:
*
How did you hear about us?
*
Word of mouth
Internet/Google
Advertising
We contacted you
Submit
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