Motor Vehicle Fact Finder
Motor Vehicle Fact Finder
Your Duty of Disclosure To be able to provide you with a quote, I have to ask you a few questions. Your answers must be accurate as they determine the basis of cover. The accuracy of your information is important as the insurer may refuse to pay or reduce the payment of any future claim.
Privacy Your privacy is important to us and Arthur J Gallagher will handle all your information in accordance with the Privacy Act 1988. Your information may be passed on to others such as insurers and claims assessors to complete your cover. If you want to access or change the information, just call us. Subject to what I have told you, do you agree to answering our questions and to the collection and disclosure of this information?
Accepted by client : Accepted by client :
DID YOU ACCESS THIS FORM VIA THE 4x4 AUSTRALIA WEBSITE? Y N
Client Details Insured Name:
Additional Insured Names:
Oldest Insured date of birth:
Correspondence Address:
Contact phone:
Email Address
Current Insurer:
Renewal Date:
4WD Club
2nd Contact No:
Current Premium or quote:
Motor Vehicle Profile If not kept at the address listed above, what is the garaging address of the vehicle?
How is the vehicle parked?
Is the vehicle under finance?
Y N
If yes, enter the name of the Financier.
Will your Financier require a Certificate of Currency?
Y N
Cover required for Vehicle Insurers offer 3 different levels of cover for motor vehicle insurance. Comprehensive covers you for damage to your car as a result of an accident, fire or theft, as well as covering you for damages caused to other people’s cars and property. Third Party, Fire & Theft covers for you damages caused to other people’s cars and property, as well as fire and theft for your car. Third Party Property Damage covers you for damages caused to other people’s cars and property only. Discuss your needs with your Arthur J. Gallagher personal broker.
What level of cover would you like? What type of value do you require?
Market value
Agreed value
If Agreed value selected, please advise the sum insured required.
OPTIONAL COVERS: A range of Optional covers are available from Insurers. Selecting these optional covers may generate an additional cost to your annual premium. Please liaise with your Arthur J. Gallagher personal broker for further details.
Cover for Under 25 year old drivers?
Maximum No‐Claim bonus protection?
Nil Excess for windscreen?
Hire car following accident?
Motor Vehicle Information Purchase date of vehicle:
Purchase price of vehicle:
What is the registration number? What is the year of Manufacture? What is the vehicle make? What is the vehicle model? What is the body type? E.g., Sedan, Hatchback, etc.. What is the transmission type? E.g., 5speed Manual, etc. What is the engine size? E.g., 1.6litre, 4 Cylinder, etc. Is the vehicle turbo‐charged?
Y
N
What colour is the vehicle? What security devices does the vehicle have fitted?E.g. Alarm, Immobilisers, etc.
Vehicle accessories & modifications Does your vehicle have accessories?
Y
N
Does your vehicle have any modifications?
Y
N
1.
$
Raised or lowered suspension (Max 4”)
Y
N
2.
$.
Computer enhanced performance chip
Y
N
3.
$
Structural modifications
Y
N
4.
$
Control arms
Y
N
5.
$
Engine replacement
Y
N
6.
$
Mag wheels
Y
N
7.
$
Larger tyres
Y
N
8.
$
If yes state full dimensions:
9.
$
Exhaust system
Y
N
10.
$
Diff lock
Y
N
11.
$
Other modifications (please provide details below)
Y
N
12.
$
13.
$
14.
$
15.
$
Total
$
Vehicle Use Is the vehicle your daily transport?
Y N
Is the vehicle used predominantly as a recreational vehicle?
Y N
Do you enter any competitions or time trials
Y N
Insurers will need to know if your vehicle is used for business purposes more than once a week on average. If you select YES, the Insurer will require further details of the business use to enable them to accept the risk.
Is your motor vehicle used in conjunction with a business?
Y N
(If yes, please proceed to the next question)
Does the business use relate mostly to the driver’s work as:
Y N
Are there goods carried in the car as part of the business use?
Y N
Pre‐existing Damage to Vehicle. Does the car have any: Rust?
Hail Damage?
Other (unrepaired) damage?
DRIVER INFORMATION Main Driver Drivers full name:
Date of Birth:
Driving %
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y N
Have you been charged with any motoring convictions in Y N the last 5 years?
Drivers full name:
Date of Birth:
Driving %
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y N
Have you been charged with any motoring convictions in Y N the last 5 years?
If YES, please provide details: 2nd Driver
If YES, please provide details:
3rd Driver Drivers full name:
Date of Birth:
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y
N
Have you been charged with any motoring convictions in the last 5 years?
Driving %
Y
N
If YES, please provide details:
4th Driver Drivers full name:
Date of Birth:
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y
N
Have you been charged with any motoring convictions in the last 5 years?
Driving %
Y
N
Has any Driver had their license suspended, cancelled or disqualified?
Y
N
Has any Driver ever been convicted of any criminal offence or been declared bankrupt?
Y
N
Has any Driver ever been refused insurance?
Y
N
Has any Driver ever had a claim refused or imposed special conditions under their policy?
Y
N
If YES, please provide details:
Additional Questions
Client Objectives Is there any additional information or special requirements we need to consider when quoting for this vehicle?
If you have completed this form digitally, save the PDF to your computer and email it to: [email protected] This form may be faxed to us on 08 8172 8100 if cover is required urgently. Original must be posted accompanied by payment to: PO Box 10016 Adelaide BC SA 5000. Thank you for taking the time to contact Arthur J. Gallagher for a quote on your motor insurance needs. We can also provide cover options for Home, Boat, Landlords, Strata, and Travel Insurance. Please let us know if we can do anything to assist you with these covers.
Your Duty of Disclosure To be able to provide you with a quote, I have to ask you a few questions. Your answers must be accurate as they determine the basis of cover. The accuracy of your information is important as the insurer may refuse to pay or reduce the payment of any future claim.
Privacy Your privacy is important to us and Arthur J Gallagher will handle all your information in accordance with the Privacy Act 1988. Your information may be passed on to others such as insurers and claims assessors to complete your cover. If you want to access or change the information, just call us. Subject to what I have told you, do you agree to answering our questions and to the collection and disclosure of this information?
Accepted by client : Accepted by client :
DID YOU ACCESS THIS FORM VIA THE 4x4 AUSTRALIA WEBSITE? Y N
Client Details Insured Name:
Additional Insured Names:
Oldest Insured date of birth:
Correspondence Address:
Contact phone:
Email Address
Current Insurer:
Renewal Date:
4WD Club
2nd Contact No:
Current Premium or quote:
Motor Vehicle Profile If not kept at the address listed above, what is the garaging address of the vehicle?
How is the vehicle parked?
Is the vehicle under finance?
Y N
If yes, enter the name of the Financier.
Will your Financier require a Certificate of Currency?
Y N
Cover required for Vehicle Insurers offer 3 different levels of cover for motor vehicle insurance. Comprehensive covers you for damage to your car as a result of an accident, fire or theft, as well as covering you for damages caused to other people’s cars and property. Third Party, Fire & Theft covers for you damages caused to other people’s cars and property, as well as fire and theft for your car. Third Party Property Damage covers you for damages caused to other people’s cars and property only. Discuss your needs with your Arthur J. Gallagher personal broker.
What level of cover would you like? What type of value do you require?
Market value
Agreed value
If Agreed value selected, please advise the sum insured required.
OPTIONAL COVERS: A range of Optional covers are available from Insurers. Selecting these optional covers may generate an additional cost to your annual premium. Please liaise with your Arthur J. Gallagher personal broker for further details.
Cover for Under 25 year old drivers?
Maximum No‐Claim bonus protection?
Nil Excess for windscreen?
Hire car following accident?
Motor Vehicle Information Purchase date of vehicle:
Purchase price of vehicle:
What is the registration number? What is the year of Manufacture? What is the vehicle make? What is the vehicle model? What is the body type? E.g., Sedan, Hatchback, etc.. What is the transmission type? E.g., 5speed Manual, etc. What is the engine size? E.g., 1.6litre, 4 Cylinder, etc. Is the vehicle turbo‐charged?
Y
N
What colour is the vehicle? What security devices does the vehicle have fitted?E.g. Alarm, Immobilisers, etc.
Vehicle accessories & modifications Does your vehicle have accessories?
Y
N
Does your vehicle have any modifications?
Y
N
1.
$
Raised or lowered suspension (Max 4”)
Y
N
2.
$.
Computer enhanced performance chip
Y
N
3.
$
Structural modifications
Y
N
4.
$
Control arms
Y
N
5.
$
Engine replacement
Y
N
6.
$
Mag wheels
Y
N
7.
$
Larger tyres
Y
N
8.
$
If yes state full dimensions:
9.
$
Exhaust system
Y
N
10.
$
Diff lock
Y
N
11.
$
Other modifications (please provide details below)
Y
N
12.
$
13.
$
14.
$
15.
$
Total
$
Vehicle Use Is the vehicle your daily transport?
Y N
Is the vehicle used predominantly as a recreational vehicle?
Y N
Do you enter any competitions or time trials
Y N
Insurers will need to know if your vehicle is used for business purposes more than once a week on average. If you select YES, the Insurer will require further details of the business use to enable them to accept the risk.
Is your motor vehicle used in conjunction with a business?
Y N
(If yes, please proceed to the next question)
Does the business use relate mostly to the driver’s work as:
Y N
Are there goods carried in the car as part of the business use?
Y N
Pre‐existing Damage to Vehicle. Does the car have any: Rust?
Hail Damage?
Other (unrepaired) damage?
DRIVER INFORMATION Main Driver Drivers full name:
Date of Birth:
Driving %
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y N
Have you been charged with any motoring convictions in Y N the last 5 years?
Drivers full name:
Date of Birth:
Driving %
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y N
Have you been charged with any motoring convictions in Y N the last 5 years?
If YES, please provide details: 2nd Driver
If YES, please provide details:
3rd Driver Drivers full name:
Date of Birth:
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y
N
Have you been charged with any motoring convictions in the last 5 years?
Driving %
Y
N
If YES, please provide details:
4th Driver Drivers full name:
Date of Birth:
Number of years licence held?
Nbr of years NCD?
Have there been any accidents or claims in the last 5 years?
Y
N
Have you been charged with any motoring convictions in the last 5 years?
Driving %
Y
N
Has any Driver had their license suspended, cancelled or disqualified?
Y
N
Has any Driver ever been convicted of any criminal offence or been declared bankrupt?
Y
N
Has any Driver ever been refused insurance?
Y
N
Has any Driver ever had a claim refused or imposed special conditions under their policy?
Y
N
If YES, please provide details:
Additional Questions
Client Objectives Is there any additional information or special requirements we need to consider when quoting for this vehicle?
If you have completed this form digitally, save the PDF to your computer and email it to: [email protected] This form may be faxed to us on 08 8172 8100 if cover is required urgently. Original must be posted accompanied by payment to: PO Box 10016 Adelaide BC SA 5000. Thank you for taking the time to contact Arthur J. Gallagher for a quote on your motor insurance needs. We can also provide cover options for Home, Boat, Landlords, Strata, and Travel Insurance. Please let us know if we can do anything to assist you with these covers.
