Private Motor Vehicle Insurance Questionaire Step 1 of 6 16% Underwriting Acceptance CriteriaHave you been declined insurance in the last 12 months?* Yes No In the last 5 years have you or any of the drivers listed has any convictions for driving under the influence of alcohol, drugs or had a license cancelled or suspended?* Yes No InsuredName of insured party/registered owner?* First name Middle Name Last Name Registered Owner Date of Birth?* MM slash DD slash YYYY Preferred email address for quote?* Acceptance CriteriaIs the vehicle registered?* Yes No Does the vehicle have any existing damage?*Excluding minor scratches, wear and tear or hail damage. Yes No Provide details of damageIs the vehicle used for any of the following purposes?*Driver education, racing or sporting events, courier or delivery services, as a hire car, courtesy car, taxi or removalist vehicle? Yes No Vehicle DetailsYear of manufacture* Make* Model* Vehicle registration number* Transmission* Automatic Manual Fuel* Diesel Petrol LPG 4x4* Yes No CoverType of cover required* Comprehensive Cover Third Party Property Damage Type of Sum Insured* Agreed Value Market Value Agreed valueInclude cover for Protect No Claim Bonus Rating?* Yes No Include cover for a hire car during repairs?* Yes No Include cover for windscreen excess waiver?* Yes No Does the vehicle have any non-standard accessories that will be included within the cover?* Yes No Details of non-standard accessoriesDoes the vehicle have any modifications that will be included within the cover?* Yes No Details of vehicle modifications Vehicle SpecificsDoes the vehicle have any of the following modifications?Specialised paint?* Yes No Nitro/ Hydrogen fuel?* Yes No Turbo/ supercharger?* Yes No Roll bar/ roll cage/ racing harness?* Yes No What security devices does the vehicle have fitted?* Alarm Vehicle tracking Other Select all that applyIf other, please specify Overnight parking address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code What is the vehicle used for?* Personal use On road professional On road sales Trades person Is the vehicle used for driver education, racing, sporting events, courier, delivery services, hire car, fare, removalist, fleet, pool or airside?* Yes No Does the vehicle have any hail damage?* Yes No Interested PartiesIs the vehicle subject to a finance agreement?* No Yes Please list any interested parties to this vehicleInclude details of finance company. DriversMain driver | Name* First Middle Last Main driver | Date of birth* DD slash MM slash YYYY Main driver | What year did you get your driver's licence?* Main driver | Claims history* 0 1 2 3 + How many claims have you had in the past 5 years?Main driver | Claims history detailsAdditional driver | Name First Middle Last Additional driver | Date of birth DD slash MM slash YYYY Additional driver | What year did you get your driver's licence? Additional driver | Claims history 0 1 2 3 + How many claims have you had in the past 5 years?Additional driver | Claims history details 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. NameThis field is for validation purposes and should be left unchanged.