Pollard Insurance Brokers Frankston Victoria Business Insurance Professional Indemnity Insurance Public Liability Insurance

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Quotation Request for Motor Vehicle Insurance

Please complete this form to request an insurance quote from our firm. Questions marked with an * are mandatory and must be completed so a response can be provided.

If you prefer to provide the information in this form directly over the phone, please indicate this below and we will contact you promptly.

Prior to submitting this form please read the following which describes our practices in relation to the handling and use of personal information.

About You

Full Name: *

Contact Number: *

Email Address: *

Tick here if you prefer to provide the information in this form directly over the phone. We will arrange for a representative to contact you promptly.

About Your Vehicle

Year of Manufacture:

Full manufacturer's description of vehicle:

Transmission Type:

No. of Cylinders:

Registration Number:

Engine/VIN or Chassis Numbers:

Purchase Price:

Current Value:

List any extras or modifications e.g. rally pack, wide rims, lowered body, air conditioner, CD system etc., which are additional to the manufacturer's standard for the model (include replacement cost of each item). State if vehicle is turbo charged.

Are you the registered owner/s of the vehicle?

If No,

(a) Please provide registered owner's name:

(b) Please indicate your interest in the vehicle:

Type of vehicle finance:

About Your Insurance Needs

Insurance Type:

How is the vehicle used?

Postcode where vehicle is usually kept:

How is the vehicle garaged at night?

Period of Insurance

From:
(commencing at 4:00pm local standard time)

(dd/mm/yyyy)

To:
(expiring at 4:00pm local standard time)

(dd/mm/yyyy)

Driver Details

Enter your own details below (even if the vehicle is not being driven) plus details of all persons whom you nominate as, or expect to be, drivers of the vehicle. Any drivers under 25 must be declared or nominated.

General

What is your current No Claim Discount/Rating?

Has the owner or any of the drivers in the LAST 5 YEARS:

(i) Had, or will have, a driver's or motorcycle rider's licence cancelled, suspended or special conditions imposed?

(ii) Had any insurance declined or cancelled, been refused renewal of any insurance, or had special terms, conditions or excesses imposed?

Has the owner or any of the drivers in the LAST 10 YEARS:

(iii) Had a conviction or been charged for driving under the influence of alcohol or drugs?

(iv) Had a conviction for, or currently charged with, any criminal offence?

Declaration

By clicking the SUBMIT button below I declare that:

(i) I have either completed this proposal form personally or, if it has been completed by someone else, the answers have been checked for fullness and accuracy by me;

(ii) If during the Period of Insurance circumstances change in the information I have provided, I will promptly inform you; and

(iii) I understand that if I have not fulfilled my Duty of Disclosure my claim may be reduced.