TEL: 1300 856 657
FAX: 02 4351 8200
Email: mta@dmainsure.com.au
Web: www.dmainsure.com.au

Motor Trades Policy Quotation

  
Please complete the following sections and click the Submit button at the bottom of the form. A PDF copy of the completed form will be emailed to both you and DMA.
* Indicates a mandatory field.

Client Details:
Client Name:
Trading As:
Survey Contact:
Telephone No:
Email Address:
Postal Address:
Current Insurer:
Policy Expiry Date: (dd/mm/yyyy)
Current Premium: $ 
Business Occupation:
Turnover: $ 
Years in Business:
Number of Employees:

General Underwriting Questions
Has any owner/director or officer of the business, or the business itself sustained more than 3 losses, or had losses totalling more than $5,000 in the last three years for those sections to be covered by this policy?: Yes  No
During the past five years, has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership?: Yes  No
During the past five years, has any owner/director/officer of the business, or the business itself been convicted of a criminal offence?: Yes  No
CurrentInsurer
Has the owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?: Yes  No

Premises Details
Situation Address:
Occupied as (occupation):
Construction:
Sprinklered: Yes  No
Security:
Deadlocks
Local Alarm
Back to Base Unsecured Alarm
Back to Base Secured Alarm
Securitel/Dedicated Line & GSM Backup Alarm
24hr Secure Office
24hr Secure Shopping Mall
Locality:
Industrial Estate
Main St
Office Block
Remote / Out of Town
Shopping Centre (Sprinklered & Locked Overnight)
Shopping Mall
Suburban St
Spray Booth: Yes  No

Fire
Excess:
$250   Other  
Other Excess Amount: $ 
Building: $ 
Contents: $ 
Stock: $ 
Full Accidental Damage Cover: Yes  No
Fusion Cover: Yes  No
Other:
Other Value: $ 

Theft
Excess:
$250   Other  
Other Excess Amount: $ 
Contents/Stock: $ 
Tobacco/Alcohol: $ 
Other:
Other Value: $ 
Tyre/Wheel/Battery in open Cover: Yes  No

Money
Excess:
$100   Other  
Other Excess Amount: $ 
Transit/Business Hours: $ 
In Safe: $ 

Glass
Excess:
$100   Other  
Other Excess Amount: $ 
Internal/External Replacement:

Machinery Breakdown
Excess:
$250   Other  
Other Excess Amount: $ 
Breakdown:
$10,000   Other  
Other Breakdown Amount: $ 
Air Conditioning Units: Yes  No

Deterioration of Stock
Excess:
$100   Other  
Other Excess Amount: $ 
Deterioration: $ 

Computer Breakdown
Excess:
$250   Other  
Other Excess Amount: $ 
Breakdown: $ 
Rewrite of Data: $ 
Increased Cost of Working: $ 

Electronic Equipment Breakdown
Excess:
$250   Other  
Other Excess Amount: $ 
Electronic Equipment: $ 
Audio Visual/Diagnostic Equipment: $ 

Business Interruption
Gross Income: $ 
Accounts Receivable: $ 
Additional Increased Cost of Working: $ 
Professional Fees:
$10,000   Other  
Other Professional Fees Amount: $ 
Indemnity Period:

Liability
Excess:
$250   Other  
Other Excess Amount: $ 
Public Liability:
Products Liability:
Professional Risks:
Customer Goods Cover:
$150,000   Other  
Customer Goods Cover Other Amount: $ 
Driving Risk: $ 

Liability Underwriting Questions
Does the business gain more than 10% of turnover from work on vehicles greater than 5 tonnes?: Yes  No
Does the business gain more than 10% of turnover from work on high performance vehicles e.g. Ferraris, Porsche etc?: Yes  No
Does the business export any products to North America?: Yes  No
Is cover required for partners/directors previous (similar) businesses? (Professional risks only): Yes  No

Portable and Valuable Items

Specified/Unspecified Items
Amount Description of specified/unspecified item and serial number
$ 
$ 

Employee Dishonesty
Excess:
$250   Other  
Other Excess Amount: $ 
Employee Dishonesty: $ 

Tax Probe®
Tax Audit Cover:
Number of Directors:

Commercial Motor
Customer Vehicles Excess:
1%, min $500   Other  
Customer Vehicles Other Excess Amount: $ 
Customer Vehicles Sum Insured: $ 
Age of Test Driver:
Tow Trucks Excess:
1%, min $500   Other  
Tow Trucks Other Excess Amount: $ 
Tow Truck 1: $ 
Tow Truck 2: $ 
Tow Truck 3: $ 
Tow Truck 4: $ 
Tow Truck On Hook Liability:
Part 1 (Accident Damage) Cover
Tow Truck On Hook Liability:
Part 2 (Liability) Cover
Year Make/Model/Rego Garage Postcode NCB Use Value Excess Youngest Driver Age
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 
$ 
$400   Other  
$ 

Commercial Motor Underwriting Questions
Has any driver of the vehicle had their license suspended or cancelled in the last 5 years?: Yes  No
Has any driver of the vehicle had any convictions relating to alcohol, drugs, dangerous driving or failing to stop after an accident in the last 5 years?: Yes  No
Has the vehicle been converted or modified by someone other than the manufacturer?: Yes  No
Do you require the Windscreen Excess Waiver Option?: Yes  No
Do you require the Rental Vehicle Option?: Yes  No

Declaration

By clicking the Submit button below I declare that:

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

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

  3. I understand that if I have not fulfilled my Duty of Disclosure my claim may be reduced.
* Indicates a mandatory field.