Complete the form below to be sent a quote through to your email.
Contact person*
Email address*
Type of use* Private useBusiness use
Cover required* Comprehensive cover (Agreed value)Comprehensive cover (Market value)Third party, fire and theftThird party only
If agreed value, enter the value
Optional Roadside Assistance* YesNo
Registration Number*
Vehicle storage* Address where vehicle is kept at night
Comprehensive cover options (Not available for TPF&T or TPO) Hire car after an accident* YesNo
No claims discount preservation?* YesNo
Do you want to restrict drivers to two people over the age of 25 years to reduce premiums?* YesNo
If 'Yes', please list the two drivers here (maximum of two)
Do you want to exclude drivers under 25 years of age and further reduce premiums?* YesNo
What excess option would you like?* $400 Excess (standard)$500 Excess$750 Excess$1000 Excess
Is the vehicle:
Registered in a name other than yours?* YesNo
If 'Yes', please give details
Under finance or lease?* YesNo
Modified in any way?* YesNo
If 'Yes', please give details A modification includes (but is not limited to) changes or enhancements to the: engine, exhaust system and suspension; panels or paint work; size and type of wheels and/or size of tyres.
Accessory cover Is the vehicle equiped with accessories (excluding Manufacturers standard fittings) with a total value over $1,000?* YesNoThis includes fitted entertainment, communications and navigation systems, child restraints/seats; tools and breakdown equipment purchased by you to repair your vehicle; car seat covers; first aid kit, torch, fire extinguisher, maps; and other equipment (not otherwise stated) permaneltly fitted to the vehicle.
If you have answered 'Yes', please provide full details
Add a second vehicle? YesNo
Type of use Private useBusiness useN/A
Cover required Comprehensive cover (Agreed value)Comprehensive cover (Market value)Third party, fire and theftThird party onlyN/A
Optional Roadside Assistance YesNoN/A
Registration Number
Vehicle storage Address where vehicle is kept at night
Comprehensive cover options (Not available for TPF&T or TPO) Hire car after an accident YesNoN/A
No claims discount preservation? YesNoN/A
Do you want to restrict drivers to two people over the age of 25 years to reduce premiums? YesNoN/A
Do you want to exclude drivers under 25 years of age and further reduce premiums? YesNoN/A
What excess option would you like? $400 Excess (standard)$500 Excess$750 Excess$1000 ExcessN/A
Registered in a name other than yours? YesNoN/A
Under finance or lease? YesNoN/A
Modified in any way? YesNoN/A
Accessory cover Is the vehicle equiped with accessories (excluding Manufacturers standard fittings) with a total value over $1,000? YesNoN/AThis includes fitted entertainment, communications and navigation systems, child restraints/seats; tools and breakdown equipment purchased by you to repair your vehicle; car seat covers; first aid kit, torch, fire extinguisher, maps; and other equipment (not otherwise stated) permaneltly fitted to the vehicle.
This part requests information on the drivers of your vehicles
Full name
Date of birth
Gender—Please choose an option—MaleFemaleGender diverse
Years Licence held
Number of at fault accidents or theft losses in the last 2 years
Vehicle no.1 % use
Vehicle no.2 % use
Have you or any of the persons who may drive the vehicle:
Had any accidents or losses in the last 2 years?* YesNo
Had a driving licence suspended, cancelled or any special conditions imposed?* YesNo
If you have answered 'Yes' to any of the above questions, please provide full details and dates:
Additional notes
