Prestige Motor Vehicle Insurance Quotation Form
Please complete the details below and we will obtain a quotation on your behalf:
Required Fields (*)
*
Contact Name:
*
Age:
*
Phone:
Fax:
*
Email:
*
Occupation:
*
Vehicle Details:
*
Current Insurer:
*
Value:
*
NCB:
%
Current Premium:
*
Suburb Kept Overnight:
*
Used For:
Private
Business
*
Is the Vehicle under Finance?
Yes
No
*
How Often is the Vehicle Driven?
Daily/Commuting to Work
Twice Weekly
Restoration/Storage Only
Daily/Non Commuting
Twice Monthly
Other (Please Describe):
*
Where is the Vehicle
Parked Overnight?
Garage
Carport
Driveway
Other:
*
Where is the Vehicle
Parked During the Day?
Home
Company Car Park
Public Car Park
Other:
*
Is the Vehicle Modified?
Yes
No (If Yes list all Modifications/Accessories)
*
Does Vehicle have any Anti-Theft Security?
Yes
No
Alarm Only (Noisemaker)
Alarm Only (Noisemaker)
Lock Tight Deadlocking
Mobile Tracking
Self Arming Immobiliser
Other Immobiliser
Other (or Additional Security)
Insured & Other Drivers' Names
Date of Birth
Full Occupation
% of Use
*
Have any of the drivers had a traffic offence (including loss of licence/special terms imposed) or had and Accident &/or Claim in the last 5 years?
Yes
No (if yes, supply full details)