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Commercial Motor Vehicle
Commercial Motor Vehicle Form
Insured Name
ABN
Email
Phone Number
Insured Address
Address Line 1
Address Line 2
City
State
Area Code
Director Name/s
The Gross Turnover Last Financial Year in Australia
The Gross Turnover Current Financial Year in Australia
The Gross Turnover Coming Financial Year in Australia
Confirm which State/Territory You Operate In
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Do You Handle Dangerous Goods?
- Select -
Yes
No
Do You Handle Asbestos?
- Select -
Yes
No
Do you Perform any Welding?
- Select -
Yes
No
Do you assume liability or contract in additional exposure?
- Select -
Yes
No
Do all subcontractors carry their own Public & Products Liability insurance?
- Select -
Yes
No
Number of Full Time Employees
Number of Part Time or Casual Employees
Is Tool & Equipment Required?
Yes
No
TOOL & EQUIPMENT - Unspecified Tools Limit (under $3,000 per item)
Would you like to insure Vehicle 1
Yes
No
COMPANY WORK VEHICLE/S - include Registration all Accessories and Modifcations
Is This A Courtesy Vehicle?
- Select -
Yes
No
Drivers including Date of Birth
Finance
If adding a vehicle - will this vehicle/s be used for Driver Education, Racing, Courier/Delivery, Hire Car, Taxi, Uber, Courtesy , Removalist
- Select -
Yes
No
Would you like to insure Vehicle 2
Yes
No
COMPANY WORK VEHICLE/S - include Registration all Accessories and Modifcations
Is This A Courtesy Vehicle?
- Select -
Yes
No
Drivers including Date of Birth
Finance
If adding a vehicle - will this vehicle/s be used for Driver Education, Racing, Courier/Delivery, Hire Car, Taxi, Uber, Courtesy , Removalist
- Select -
Yes
No
Would you like to insure Vehicle 3
Yes
No
COMPANY WORK VEHICLE/S - include Registration all Accessories and Modifcations
Is This A Courtesy Vehicle?
- Select -
Yes
No
Drivers including Date of Birth
Finance
If adding a vehicle - will this vehicle/s be used for Driver Education, Racing, Courier/Delivery, Hire Car, Taxi, Uber, Courtesy , Removalist
- Select -
Yes
No
Drivers including Date of Birth
If adding a vehicle - has any drivers lost licence or been suspended
- Select -
Yes
No
If adding a vehicle - has any drivers had any traffic convictions
- Select -
Yes
No
Previous Claims Declined?
- Select -
Yes
No
Ever been liable for any civil offence or pecuniary penalty?
- Select -
Yes
No
Ever been charged or convicted of a criminal offence?
- Select -
Yes
No
Ever had an insurance policy cancelled, declined or terms imposed?
- Select -
Yes
No
Aware of circumstances which could give rise to a claim?
- Select -
Yes
No
Anything to Declare under Duty of Disclosure?
- Select -
Yes
No
Additional Information about you or the property
Submit Form
