4WD Policy Application Form

Before completing, read "Duty of Disclosure"
1. The full name of the person(s), company or partnership applying for this insurance
  ABN (Where applicable) email
  Title Last Name
  Given Name(s) Date of Birth
2. Your postal address
  Suburb State Postcode
3. Your occupation
4. Contact numbers Phone Mobile
5. Period of Insurance
  When would you like your insurance to start and finish? From to 4pm on
6. Finance Provider (if none, please write "Nil") Name
  Address Postcode
  Lease Secured Finance Other
Vehicle details
7. Tell us about your vehicle
Registration Number Make (e.g. Toyota) Model (e.g. Landcruiser) Year of Manufacture Body Type (e.g. Wagon) Badge (e.g. 80 series GLX) No. of Cylinders
Cubic Capacity Transmission Turbocharged Vehicle Identification No. Engine No. Date Purchased Purchase Price
cc Manual Auto Yes No $
8. Where is the vehicle kept?
  (a) Postcode (b) Is it kept in a lockable yard or building? Yes No
9. What equipment is fitted to your vehicle (not supplied and fitted by the manufacturer)?
  Equipment Fitted Fitted Cost Date Fitted
  $
  $
  $
  $
  $
  $
10. What is your estimate of the current value of the vehicle without the equipment fitted to your vehicle listed in Question 9 above? $ 
Driver details
11. The policy does not cover any drivers under 25 years of age unless we agree in writing.
  Do you want cover for any drivers aged under 25? Yes No
  If "Yes," list the drivers
  Last Name Given Name(s) Date of Birth
 
 
12. Date of birth of the youngest driver
  If you are claiming a No Claim Bonus, please attach proof and advice:
13. Previous Insurer
14. Policy Number
History
In the last 5 year, have you or anyone who may drive your vehicle:
15. been charged or convicted of arson, theft of any other ciminal act? Yes No
16. had a motor traffic offence, fine or charge pending (excluding parking)? Yes No
17. had a driver's or rider's licence cancelled, restricted or been under suspension? Yes No
18. had a motor vehicle accident, theft of any claim under motor insurance policy? Yes No
19. suffered from any physical or mental disability (except eyesight corrected by lenses)?? Yes No
20. If "Yes" to any of the above, please give details.
Duty of Disclosure

What you need to tell us

You must tell us everything that you know, or should know, that could affect our decision to insure you and/or the terms on which we insure you. You must do this when you apply for a policy, renew your policy and when you change or reinstate your policy. When we ask you specific questions, you must answer these questions truthfully and in a way that a reasonable person in the circumstances would answer them. It is important that every person who will be insured by the policy answers all questions in this way. These requirements are part of the Insurance Contracts Act 1984.

What you do NOT need to tell us

You do not need to tell us anything that:

  • reduces our risk
  • is of common knowledge
  • we know, or as an insurer should already know
  • we say that we do not want to know

What will happen if you do not tell us

If you withhold relevant information or you do not answer our questions in the way we have described, we can reduce the amount we pay for your claim, or we can cancel your policy. If your failure to tell us is fraudulent, or your answers are untruthful, we can treat your policy as if it never existed.
Declaration
You declare that:
(a) You have received a copy of the policy wording and have read the Duty of Disclosure
(b) The answers given on both pages of this proposal are true and you have complied with the Duty of Disclosure
(c) You give us authority to exchange information about any insurance or claims history with other insurers or any insurance or credit reference bureau
(d) Statements made in this proposal by one person are to be treated as made by all the people to be insured.
Have you answered all the questions?

For more information and an obligation free quote ring
(03) 8636 9001