Commercial Motor Insurance Questionnaire

General Information

Client Type*

ABN

If applicable

Company name

If applicable

Trading as

If applicable

Person completing this form*

First Last

Contact email address*

Contact number*

Capacity/ relationship*

Operations

Occupation*

Number of employees*

Number of years operating this specific business?

Number of years continuous previous commercial motor insurance?

Base of Operations

Full business address*

Not postal address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Vehicle Usage

Will any of the vehicles be used:

Select any that apply

For food preparation or sale (e.g. mobile food vans or trucks)

For promotional purposes (e.g. broadcast van, advertising)

For courier purposes (not including Bulk parcel delivery)

As mobile accommodation or office/work space

In the filming industry (e.g. wardrobe & make-up van, stunt vehicles)

For any other purpose which requires a specialised fit-out

Will any of the vehicles be used:

Select any that apply

Within the vicinity of an aircraft or confines of an airport

On rail tracks of any kind or on water

In an aboveground mining or quarry site

Underground

On a beach, sand dunes, or other tidal prone locations

Any off-road locations not listed above

Will any of the vehicles be used as a:

Select any that apply

Taxi

Rideshare vehicle

Hire car/bus

Limousine

Shuttle bus

Rental vehicle of any kind, including dry hire and courtesy vehicle

Duty of Disclosure

Have you or any partner(s) or director(s) of the business:

Ever had an insurance policy cancelled, declined or terms imposed?*

Yes

Ever been declared bankrupt?*

Yes

Ever been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?*

Yes

Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?*

Yes

Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?*

Yes

Any matters you should disclose?*

Yes

Please provide details

Driver History

In the last 5 years, has any person who is likely to drive the insured vehicle(s):

Had any convictions or had any penalties imposed for driving under the influence of alcohol or drugs?*

Yes

Had a drivers licence cancelled or suspended or restricted?*

Yes

Been convicted or charged with any driving offences or issued any speeding or traffic infringements (other than parking offences)?*

Yes

Had any motor vehicle insurance refused?*

Yes

Please provide details

Drivers

Main drivers year of birth?*

Are there any drivers under 25 years old?*

Yes

Motor Claims History

Had any insurer decline a claim?*

Yes

In the past 5 years have you or any of your drivers or subcontractors had any motor vehicle insurance claims or incidents?*

Yes

Public Liability Claims History

In the past 5 years have you or any of your drivers or subcontractors had any public liability claims or incidents?*

Yes

Duty of Disclosure

Your duty of disclosure*

Before you enter into an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984. If we ask you questions that are relevant to our decision to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. You have this duty until we agree to insure you. If you do not tell us something If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

I have read and I understand my duty of disclosure.

Phone

This field is for validation purposes and should be left unchanged.