Insured Name(Required) ABN Website Address Email PhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Stamp Duty ExemptNSW Small Business ExemptionNot For Profit or Charitable ExemptionN/APlease provide a copy of your exemption declarationPolicy Commencement Date DD slash MM slash YYYY Policy Expiry Date(Required) DD slash MM slash YYYY Business Occupation(Required) Duty of Disclosure - Have you ever or any partner(s) or director(s) of the business:(Required) Ever had an insurance policy cancelled, declined or terms imposed? Ever been declared bankrupt? Ever been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration? Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)? Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? Any other matters you should disclose? None of the above If YES to one or more of the above, please provide details Driver History - In the last 3 years, has any person who is likely to drive the insured vehicles(s):(Required) Had any convictions or had any penalties imposed for driving under the influence of alcohol or drugs? Had a drivers licence cancelled or suspended or restricted? Been convicted or charged with any driving offences or issued any speeding or traffic infringements (other than parking offences)? Had any motor vehicle insurance refused? If YES to one or more of the above, please provide details Claims - In the last 3 years, has any person who is likely to drive the insured vehicle had any Motor Vehicle claims?(Required)DateDescriptionAmount Add RemoveVehicle Details(Required)YearMakeModelRego No. Add RemoveBasis of ValuationVehicle NumberMarket ValueAgreed Value Add RemovePlease choose between Market Value or Agreed Value. If Agreed Value please note value requiredDoes the vehicle have any non-standard accessories, modifications or attachments that will be included within the cover?Vehicle NumberDescriptionValue Add RemovePlease provide details and values for each itemIs the vehicle used for:(Required) Hire including passenger transport, rideshare, courtesy car or taxi Courier or delivery services Racing or sporting events Do you wish to note any interested parties? Name of financier and nature of interestDrivers Details(Required)First NameSurnameDOB Add RemoveConsent(Required) I/We declare that the whole of the above information and answers are true in every detail and no information has been withheld. Name(Required) First Last Date(Required) DD slash MM slash YYYY File Drop files here or Select files Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB. CAPTCHA
