Prestige Motor Insurance Questionnaire

Please complete the following form with as much detail as possible to enable us to get the best possible quotation and insurance solution for your requirements. When completed please submit by clicking the submit button at the bottom of the form. Your personal broker will be in contact very shortly. Thank You.

Name
DOB
Address
Contact Number
Email Address

Vehicle Details

Make & Model of Vehicle
Year of Manufacture
Years of Ownership
Registration Number
Registered Owner
Registered Use
 Private      
 Business
Capacity and Cylinders
VIN/ Chassis Number
Transmission
 Automatic  
 Manual  
 Tiptronic 
Fuel type
 Petrol         
 Diesel      
 LPG           
 Hybrid
Sum Insured
 Market
 Agreed Value $  
Financed
 No                  
 Yes - Finance Company:  
Current Odometer Reading
Optional Accessories
Modifications
Security
 Alarm         
 Kill Switch     
 Immobiliser
 Self-Arming Immobiliser  
 Tracking
None          
Existing Damage
Overnight parking
Address:   
Suburb:     
Postcode: 
 
 Locked Garage   
 Unlocked Garage 
 Carport  
 Driveway     
 Car Park     
 On Street
Type of Cover
 Comprehensive - Daily & Commuting use  
 Comprehensive - Daily (Non- commuting)
 Comprehensive - Limited use (< 6,000k per year)
 Comprehensive - Extreme limited use (< 3,000k per year)
 Comprehensive – Concessional cover/Club Registration
 Laid up/Storage Cover only

Driver details

Driver Name Gender DOB Years Driving % of use

Driver 5 years traffic incident history

Driver Date Details of incident (DUI/Speeding/Cancellation etc) Penalty

Driver 5 years claims history

Driver Date Details of claim

Is your vehicle currently insured? Yes     No

If yes please provide details in the spaces below
Insurer
Policy Name
Policy Number
Premium
Excess
Renewal Date

Duty of Disclosure

In the last 5 years have you ever: Y/N

Had a proposal/renewal declined or had a claim refused?

Had a policy cancelled?
Had conditions imposed on an insurance policy?
Declared bankruptcy?
Any criminal convictions (other than traffic infringements)?
If any answer is ‘Yes”, please provide details below.

Declaration by Client

 

By signing this document I/we declare that:

 

  1. The statements in this Needs Analysis are true & correct
  2. That all maters disclosed to my/our knowledge you should be aware of and in particular, I/we have fully disclosed my/our Objectives, Financial Situation and Needs relevant to this insurance.
  3. That no Insurance Company has ever cancelled, declined or refused to renew or imposed special terms or cancelled any Policy held by me/us.
  4. That I/we agree to accept the terms, exclusions, conditions and limitations of the Policy(s) effected on my behalf by you in respect of the insurances obtained in respect of the above.
Client Full Name:
Signature:
Date:

 

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