Please provide us with as much information as possible to assist us in helping you with your enquiry. However only items marked with (*) are required, once we have this information one of our representatives will contact you to assist with your enquiry. |
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| Last Name (*) |
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| First Name (*) |
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| Address 1 |
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| Address 2 |
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| SUBURB (*) |
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| STATE (*) |
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| Postcode (*) |
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| Contact Telephone (*) |
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| Alternative Telephone |
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| Facsimile (if available) |
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| E-mail (*) |
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| How should we contact you? |
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| Motorhome Type |
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| Year Built |
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| Gross Vehicle Mass |
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| # Years Lic for this vehicle |
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| Registration Number |
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| Vin Number |
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| Serial Number |
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| Date of Birth |
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| Name of Financier |
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| Amount Insured |
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| Accessories Amount Insured |
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| List Accessories |
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| Did you buy your Motor Home new? |
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| Year of Purchase? |
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| Purchase Price |
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| Description of Trailer |
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| Value of Trailer? |
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| Annexe Sum Insured |
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| Contents Limit |
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| Portable Personal Valuables |
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| Portable Personal Valuables Description |
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| No Claims Bonus Years if applicable |
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Questions Section |
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| Has any insurer declined to insure you? |
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| Has any insurer declined to renew a policy? |
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| Have you ever been charged with insurance fraud? |
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| Are you an undischarged bankrupt? |
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| Have special conditions ever been set on a policy? |
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| Has an increased excess ever been imposed |
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| Have you had any prior claims rejected? |
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| Details if YES to above |
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| Tell us of any criminal charges |
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| Who is your current insurer? |
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| Policy Number |
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| Will you be claiming a GST Input Tax credit? |
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| If so what % of GST will you claim as ITC? |
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| How did you find us |
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| # of Motor vehicle accidents you have had in last 5 years |
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| # of Motor vehicle fines you have had in last 5 years |
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| Have you ever had your driver's license or permit…(please tick most appropriate) |
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| Accident and Fines Details |
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| How many motor vehicle claims you have had in last 5 years |
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| Claim Details |
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| Name of Insurer |
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| Will anyone under the age of 25 drive the vehicle? |
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| Age of youngest driver |
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| Privacy Statement |
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| (*) |
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