| Type of Insurance Required |
|
Commercial Vehicle Insurance Quote |
Policyholder One Full Name: |
|
| Policyholder One Date of Birth: |
|
| Policyholder One Occupation: |
|
| Policyholder Two Full Name: |
|
| Policyholder Two Date of Birth: |
|
| Policyholder Two Occupation: |
|
| Postal Address: |
|
| Telephone (Home): |
|
| Telephone (Work): |
|
| Telephone (Mobile): |
|
| Email Address: |
|
Vehicle One Particulars:
|
|
| |
Year |
|
| |
Make |
|
| |
Model |
|
| |
Series |
|
| |
Body Type |
|
| |
No. Cylinders |
|
| |
Registration Plate |
|
| |
Engine Number |
|
| |
Transmission |
|
| |
Garaged |
|
Vehicle Two Particulars: (call us if you have more than two vehicles)
|
|
| |
Year |
|
| |
Make |
|
| |
Model |
|
| |
Series |
|
| |
Body Type |
|
| |
No. Cylinders |
|
| |
Registration Plate |
|
| |
Engine Number |
|
| |
Transmission |
|
| |
Garaged |
|
Are any vehicles gas converted? |
(and a Standards Specifications Certificate has been issued) |
Vehicle Finance
|
|
Vehicle Modifications:
Does the vehicle have any modifications that have altered or enhanced the performance, affected the safety, or changed handling characteristics beyond the manufacturers specifications? |
|
|
|
Accessories: Do you require cover for the following? |
| |
Gates |
|
| |
Tarps |
|
| |
Dogs & Chains |
|
| |
Binders |
|
| |
Non-removable Items: including fixed hard wired car phones, also agitators or plant. |
|
Previous History: |
Radius of Operation: Will any driver be under 25 years of age or have less than 4 years driving experience for the class of vehicle in their charge: |
|
|
|
Nature of Operations: |
| |
Vehicle / Machinery Carrier |
% of total usage |
| |
Furniture Removalists |
% of total usage |
| |
Parcel Express |
% of total usage |
| |
Brick / Block / Tile Carrier |
% of total usage |
| |
Sand / Gravel Carrier |
% of total usage |
| |
Coal / Mineral Carriers |
% of total usage |
| |
Livestock Carrier |
% of total usage |
| |
Grains Carrier |
% of total usage |
| |
Produce Carrier (non-refrigerated) |
% of total usage |
| |
Produce Carrier (chilled) |
% of total usage |
| |
Refrigerated Goods Carrier |
% of total usage |
| |
Premix Concrete Carrier |
% of total usage |
| |
Tanker (non-hazardous) |
% of total usage |
| |
Garbage Waste Disposers |
% of total usage |
| |
Hazardous / Dangerous Goods Carrier |
% of total usage |
General Freight: |
| |
Foodstuffs / Clothing |
% of total usage |
| |
Hardware Supplies |
% of total usage |
| |
Sawn Timber Products |
% of total usage |
| |
Agricultural Supplies / Machine |
% of total usage |
| |
Packaged Hazardous Goods (eg. chemicals) |
% of total usage |
| |
Fertilisers |
% of total usage |
| |
Steel |
% of total usage |
| |
Other
|
% of total usage |
Earthmoving & Miscellaneous Equipment: |
| |
Road Construction & Maintenance |
% of total usage |
| |
Mining & Quarry Use |
% of total usage |
| |
Logging & Allied Occupations |
% of total usage |
| |
Bridge & Dam (Construction & Maintenance) |
% of total usage |
| |
Bush Clearing, Pulling, Rooting |
% of total usage |
| |
General Excavation:
Sewerage
Pool Installation
Clearing Building Sites
Other
|
% of total usage
% of total usage
% of total usage
% of total usage |
Previous History: |
|
