Motor Insurance...

For a competitive quote, please complete and submit the form below.

If you have already spoken to someone in our office, please note their name here so that this form can be processed by them as they will know something about you already.

Brokers Name: 

Insured Details...

Insured Names:

Email Address:

Telephone No:


Underwriting Questions...

Registration No:

Full Address (where parked at night):


The vehicle is usually parked overnight?


Type of Finance


Vehicle use


Is the vehicle fitted with any non-standard or after market accessories (excluding manufacturer optional accessories)?
Yes    No


Is the vehicle modified?
Yes    No

Driver Details...

Name of main driver:

Date of birth of main driver: 


Has the insured had any at fault incidents in the last 3 years?
Yes    No


Does vehicle have any hail damage?
Yes    No


In the last 5 years have you had any convictions for driving under the influence of alcohol, drugs or had a licence cancelled or suspended?
Yes    No


Has the insured had any insurance declined, renewal refused, terminated or special conditions imposed by any insurer?
Yes    No


Has the insured ever been declared bankrupt or gone into liquidation?
Yes    No


Has the insured had a criminal conviction or conviction pending?
Yes    No


Type the above number:


By submitting this Declaration, I/we declare and agree that:
  • I/we have the consent of all other persons covered by this policy to make this Declaration,
  • the contents of this Declaration are true and complete,
  • I/we have read the information concerning the duty of disclosure (immediately below this declaration) and other important notices;
  • I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;
  • I/we realise that if I/we have not complied with the duty of disclosure, any claims may not be met
  • if anything happens during the Period of Cover which alters any of the information provided, I/we will promptly inform the insurer;
  • they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.
Name of person making this declaration:




Important - Under the terms of the Financial Services Act we are required to supply a copy of our "Financial Services Guide" (FSG). You can view this guide by clicking on the following link - "Financial Services Guide (FSG)"