Commercial Motor Insurance Questionnaire "*" indicates required fields Step 1 of 7 14% General InformationClient Type*IndividualSole TraderBusinessABN If applicableCompany name If applicableTrading as If applicablePerson completing this form* First Last Contact email address* Contact number* Capacity/ relationship*Owner of vehicle/businessEmployee of businessOther OperationsOccupation* Number of employees*Number of years operating this specific business? Number of years continuous previous commercial motor insurance? Base of OperationsFull business address*Not postal address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Vehicle UsageWill 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 DisclosureHave you or any partner(s) or director(s) of the business:Ever had an insurance policy cancelled, declined or terms imposed?* Yes No Ever been declared bankrupt?* Yes No 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 No Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?* Yes No Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?* Yes No Any matters you should disclose?* Yes No Please provide details Driver HistoryIn 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 No Had a drivers licence cancelled or suspended or restricted?* Yes No Been convicted or charged with any driving offences or issued any speeding or traffic infringements (other than parking offences)?* Yes No Had any motor vehicle insurance refused?* Yes No Please provide details DriversMain drivers year of birth?* Are there any drivers under 25 years old?* Yes No Motor Claims HistoryHad any insurer decline a claim?* Yes No In the past 5 years have you or any of your drivers or subcontractors had any motor vehicle insurance claims or incidents?* Yes No Public Liability Claims HistoryIn the past 5 years have you or any of your drivers or subcontractors had any public liability claims or incidents?* Yes No Duty of DisclosureYour 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. PhoneThis field is for validation purposes and should be left unchanged.