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 Motor Vehicle Insurance Online Quote Form

 

 

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Motor Insurance Online Quote Form

 

BUSINESS USE VEHICLES ONLY

 

Please complete the following information and submit this form to obtain an insurance quotation.

 

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

 

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

INSURED'S - Details
 
Registered Owner*    
Name/Main Driver*

Date of Birth*

 / /

  Garaging Address*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

 

VEHICLE - Details
 
 Year*
 Make* (e.g. Holden, Ford, Toyota etc)
 Model* (e.g. Commodore, Falcon, Camry etc)
Type of Model* (e.g. Executive, Acclaim, GLI, Futura, CSI etc)
 Vehicle Type* (e.g. Sedan, Wagon, Van, etc)
 Registration Number*
 Cyl*
 Turbo
 Transmission
 Anti Theft Devices

If other provide details

  
 Financed

Name of Finance Company

  
 Vehicle Use

 if business provide details

  
 Vehicle Value*
 Overnight Parked In

 if other provide details

  
 

 INSURANCE – Details
 
Type Of Cover

Sum Insured

Rating 1 Protection

Windscreen Protection

Hire Car Following an Accident

Increase Excess to reduce premium

 

 PREVIOUS INSURANCE - Details
 
 Currently Insured?             if yes, please provide the date it expirers* / / & The Insurer*
 Current Rating
 Any there any Modifications or Accessories to the Vehicle?

 Have you ever suffered any losses or claims or accidents?

 Have you ever had any insurance cancelled or declined or special terms imposed?

 

 Have you ever been charged or convicted of any criminal offence or driver convictions or declared bankrupt?

 

 Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?

 

 

 CONTACT – Details
 

First Name*

Surname*

  Phone No   (please include area code)

  Fax No

   (please include area code)

  Email Address*

 

 

How did you find us?*
if other, please provide details

 

 

 

 

 *Mandatory Fields

Thanks for completing our online form.

We will endeavour to contact you with your insurance details soon.

Meanwhile, if you require any further assistance please feel free to contact us.

            

                                                                                          

 

We may need to contact you to obtain additional information to provide you with an insurance quotation.

Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.