Add a Vehicle Adviser Name (if known) First Name Last Name What would you like us to do? (our Scope of Service) * Add a vehicle to my existing policy Replace existing vehicle on my policy Your Name * First Name Last Name Are you the registered owner of the vehicle? * YES NO What is your date of birth? MM DD YYYY Phone (###) ### #### Email Address Address 1 Address 2 City State/Province Zip/Postal Code Country Address vehicle will be located if different from above Address 1 Address 2 City State/Province Zip/Postal Code Country What date do you want cover effective from? MM DD YYYY Vehicle Details Will there be any business use of the vehicle? YES NO What is the estimated market value of the vehicle currently? - $ Does the above figure include or exclude GST? incl. GST excl. GST Not sure Type of Cover Comprehensive Third Party Fire & Theft Third Party Vehicle details Registration Number / Year / Make / Model/Sub Model / Body Type / No. Of Doors / Engine Size / Transmission (Manual/Auto) Is there an alarm? YES NO Is there an immobiliser? YES NO Under finance or lease? YES NO Does the vehicle have accessories with a total value over $1,000 or has it been modified? YES NO Base Excess 500 600 850 1100 Been aware of any damage from flooding, landslip or earthquake at any address relating to this policy? YES NO Declaration & Privacy Statement By ticking this box, I confirm I have read and understood the following declaration and privacy statements On completion of this form our advisers will send you a Scope of Service and Disclosure Statement. If you have any questions prior to completing this form, please contact us. Additional notes or queries that may affect your insurance? Accept Thank you! Book a free consultation Book consultation
