Commercial Motor Insurance Form

Contact Name:*
Email:*
Phone Number

Legal Entity:
Trading Name:*
ABN
Website:
Mailing Address
Number :
Street:
Suburb:
State:
Postcode:

Description
Year:
Make:
Model:
Registration Number
Cover Required
Sum Insured Required
If Agreed Value, Please Specify Value
Garaging Address
Number :
Street:
Suburb:
State:
Postcode:
Garaging Type
Is the vehicle refrigerated?
Will you be carrying any pesticides/chemicals or dangerous goods?
If Yes, then how many litres carried at any one time
Are there any drivers under the age of 25?
Driver name
DOB
Is the vehicle financed?
If Yes, then provide details
Security Devices
Are there any accessories or modification on the vehicle?
If yes please note the type, make, model and value

Have you been declined insurance in the last 12 months?
HAVE YOU HAD ANY CRIMINAL CONVICTIONS IN THE LAST 5 YEARS?
Have you or any drivers had any claims or accidents in the last 5 years?
Have any drivers had their licences cancelled or suspended?
If yes to any of the above, please provide details

This declaration must be completed and signed by or on behalf of the party applying for insurance.
The proposer/I/We

  1. declare that:
    1. the answers and information given by me/us in this Application are true and correct in all respects;
    2. no information has been withheld that would affect an insurers decision to accept this Application;
    3. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;
    4. I/we have read and understood the Financial Services Guide and Privacy Statement;
    5. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

  2. authorise Wallace Risk Solutions to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Name