QUOTE REQUEST – BROKERS.

Prestige Motor Vehicle Quotation Request For Insurance Brokers
Brokerage*
Brokerage Office
State*
Contact Name*
Phone No*
Broker Email*
Email me a copy
- Yes Please
Client Name*
Vehicle Year/Make/Model*
Accessories
Modifications
Transmission*
- Manual
- Automatic
- Tiptronic
Type of Cover Requested*
- 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:*
If Purchased in Last 12 months
Purchase Price:
Purchase Date
DD slash MM slash YYYY
No Claim Bonus or Rating No*
Use of Vehicle*
- Private
- Business
Occupation*
Finance*
- Yes
- No
Financier*
Suburb where vehicle is left overnight*
Postcode*
Parked overnight in*
- Garage
- Carport
- Driveway
- Other
If Other*
(Overnight street parking at or near the nominated parking facility is not acceptable.)
Security Device Fitted?*
- Yes
- No
If yes, details of immobiliser or tracking system
Driver Details*
First Name Last Name % of Use Date of Birth (dd/mm/yyyy)

Please ensure % of Use totals 100% across all drivers.
Note:
1. Drivers less than 25 years of age not acceptable (30 in some cases).
2. Approved drivers must be licensed in Australia or New Zealand (provisional licenses excluded).
In the LAST THREE (3) YEARS have any of the above drivers had any accidents, vehicles stolen or burnt, or any other losses involving a vehicle where an insurance claim has been made?*
- Yes
- No
Please provide details*
Driver Name Description of Loss Date of Loss Cost of Loss
In the LAST THREE (3) YEARS have any of the above drivers committed any traffic offences which resulted in a fine or demerit points being imposed or for which a conviction was recorded?*
- Yes
- No
Please provide details:*
Driver Name Description of Offence Date Penalty Imposed If Speeding, kms over limit
Your Duty When You Apply For Insurance

By proceeding, you confirm that you have read the following important information.

By law, you must take reasonable care not to make a misrepresentation. This means giving us true, complete and accurate answers to our questions, including where you provide information on someone else’s behalf. We use your answers to decide whether to insure you and on what terms.

If any of your answers are misleading, incomplete, inaccurate or fraudulent we may reduce or not pay a claim, cancel your policy or treat it as if it never existed.

If you don’t understand a question, you’re unsure how to answer or if anything is unclear, please call us.
I acknowledge that I have read and agree to the Terms and Conditions and confirm I have complied with My Duty When I Apply for Insurance when answering these questions.*
- I Agree
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Driver Name	Description of Offence	Date	Penalty Imposed	If Speeding, kms over limit

First Name	Last Name	% of Use	Date of Birth (dd/mm/yyyy)

Driver Name	Description of Loss	Date of Loss	Cost of Loss

ABOUT US

QUOTE REQUEST – BROKERS.

Prestige Motor Vehicle Quotation Request For Insurance Brokers

Note:

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