CFGSite - Motor Insurance

Contact Details

First Name *

Last Name

Phone *

Email Address *

Vehicle Details

Name of Registered Owner *

Vehicle Year *

Vehicle Make *

Vehicle Model *

Transmission *

ManualAutomatic

Type of Cover required *

Comprehensive (unlimited kms)Comprehensive ‘Limited Kilometres’ (Limited to 5,001-8,000 kms per year)Comprehensive ‘Low Kilometres’ (Limited to 0 – 5,000 kms per year)

Agreed Value ($) *

What is the vehicle used for? *

PrivateBusinessPrivate and Business

Is there finance on the vehicle? *

YesNo

Financier *

Address where the vehicle is left overnight *

Street address *

City *

State *

Postcode *

The vehicle is parked overnight in:

GarageCarportDrivewayOther

Please specify *

Is a security device fitted in the vehicle? *

YesNo

Please provide details *

Driver Details

Please include the details of all those who drive the vehicle. The total % must equal 100%.

Name

% of Use

Date of Birth

Duty of Disclosure

Drivers less than 25 years of age not acceptable (30 in some cases).
Approved drivers must be licensed in Australia or New Zealand (provisional licenses excluded).

In the last three (3) years, have any of the drivers had any accidents, vehicles stolen or burnt, or any other losses involving a vehicle where an insurance claim has been made? *

YesNo

Driver Name

Description of Loss

Date of Loss

Cost of Loss

In the last three (3) years, have any of the drivers committed any traffic offences which have resulted in a conviction or for which a penalty has been imposed or points lost? *

YesNo

Driver Name

Description of Offence

Offence Date

Penalty Imposed

If speeding, kms over limit

Comments / Additional Information