(08) 8332 0281 insurance@ssaains.com.au

Motor Vehicle Insurance

Insured details

First name*
Surname*
Date of Birth*

Home phone
Work phone
Fax number

Mobile phone
Email address*

Postal address
Suburb/town
State

Postcode

Over 55 & Retired?*
YesNo

Preferred Method of Contact?*
EmailPhoneFax

SSAA membership number (if applicable)

Vehicle Details

Year of manufacture*
Make*
Full model details*

Engine size*
Registration number*
Body type*

Purchase Price*
Colour

Transmission type*
Auto TouchtronicAutomaticManualTiptronic

Is the vehicle fitted with an alarm?*
YesNo

Is the vehicle fitted with an immobiliser?*
YesNo

Is the vehicle turbocharged?*
YesNo

Is the vehicle roadworthy & registered?*
YesNo

Modifications, please supply details and value
Accessories, please supply details and value

Vehicle use?
PrivateBusiness

If business, occupation

Kept overnight at postal address?
YesNo

Address where vehicle is kept overnight

Address

Suburb

State

Postcode

Other

Garaging Details?*
GarageDrivewayCarportStreet

Financed?*
YesNo

Yearly distance travelled?
Up to 5000kmUp to 15000kmUp to 20000kmMore than 20000km

Vehicle policy cover and history

Current no claim bonus or rating?*
0%/0yrs20%/1yr30%/2yrs40%/3yrs50%/4yrs60%/5yrs

Current insurer*
Expiry date*

Current excess*
Current premium*

Type of cover?*
Comprehensive (Market Value)Agreed ValueThird Party Fire & Theft (Market Value)Third Party Property Damage

Agreed value cover amount (if applicable)

Policy options

No Claim Bonus Protection (if Rating 1)?*
YesNo

Excess free Windscreen cover?*
YesNo

Restricted Driver Discount (excludes cover for under 30 year olds)?*
YesNo

Named Driver Option?*
YesNo

Car Rental Following an Accident?*
YesNo

Drivers

Number of drivers*

Driver 1

Name*
Date of birth*
Year licence obtained*

Owns this vehicle*
YesNo

Registered owner of another vehicle*
YesNo

Driver 2

Name
Date of birth
Year licence obtained

Owns this vehicle
YesNo

Registered owner of another vehicle
YesNo

Driver 3

Name
Date of birth
Year licence obtained

Owns this vehicle
YesNo

Registered owner of another vehicle
YesNo

Driver 4

Name
Date of birth
Year licence obtained

Owns this vehicle
YesNo

Registered owner of another vehicle
YesNo

Driver 5

Name
Date of birth
Year licence obtained

Owns this vehicle
YesNo

Registered owner of another vehicle
YesNo

Insurance history

Has any applicant been declared bankrupt and not discharged for at least one year?*
YesNo

If Yes, please supply details

During the past 5 years has any applicant or driver had any:

(1) Insurance declined or cancelled?*
YesNo

If Yes, please supply details

(2) Renewal declined or refused?*
YesNo

If Yes, please supply details

(3) Excess or special conditions imposed?*
YesNo

If Yes, please supply details

(4) Driver’s licence or learner’s permit cancelled, suspended, disqualified, reduced to a lesser grade or had special conditions imposed?*
YesNo

If Yes, please supply details

(5) Prior accidents or claims with another insurer for motor insurance?*
YesNo

If Yes, please supply details

(6) Motor vehicles burnt or stolen?*
YesNo

If Yes, please supply details

(7) Driving offences, infringements, convictions or currently have any of these pending?*
YesNo

If Yes, please supply details

(8) Convictions for DUI of alcohol or drugs?*
YesNo

If Yes, please supply details

(9) Prior claims rejected?*
YesNo

If Yes, please supply details

During the last 10 years has any applicant had any criminal conviction relating to drugs, dishonesty, arson, theft, fraud or violence against any person or property?*
YesNo

If Yes, please supply details

I have read the Duty of Disclosure. (View)