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Car Buyer
Employer
Clear Lease Driver
Calculate Savings
News
About Us

Car Buyer
Employer
Clear Lease Driver
Calculate Savings
News
About Us

Menu

Car Buyer
Employer
Clear Lease Driver
Calculate Savings
News
About Us

Car Buyer
Employer
Clear Lease Driver
Calculate Savings
News
About Us

Menu

Car Buyer
Employer
Clear Lease Driver
Calculate Savings
News
About Us

Insurance Application

Step 1 of 5

20%

Driver Contact Details - Lessee

Name(s) of Registered Owner(s) of the car

Name(Required)

First Last

Residential Street Address(Required)

Suburb(Required)

State(Required)

Postcode(Required)

Contact Numbers

Mobile No.(Required)

Work Phone No.(Required)

Email Address(Required)

Hidden

Name of Employer(Required)

Driver(s) details

Enter Main Drivers First

Number of Drivers to be covered on this policy(Required)

Please enter a number from 1 to 5.

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Sex M/F(Required)

% Use of vehicle(Required)

Please enter a number from 1 to 100.

Year License obtained in Australia(Required)

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Sex M/F(Required)

% Use of vehicle(Required)

Please enter a number from 1 to 100.

Year License obtained in Australia(Required)

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Sex M/F(Required)

% Use of vehicle(Required)

Please enter a number from 1 to 100.

Year License obtained in Australia(Required)

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Sex M/F(Required)

% Use of vehicle(Required)

Please enter a number from 1 to 100.

Year License obtained in Australia(Required)

Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Sex M/F(Required)

% Use of vehicle(Required)

Please enter a number from 1 to 100.

Year License obtained in Australia(Required)

Car details

Security Features

After-market Alarm?

Yes

No

After-market Immobiliser?

Yes

No

After-market Electronic tracking?

Yes

No

After-market Accessories?

Yes

No

Tow bar, bull bar, window tint etc

Please provide details of any modifications from the manufacturers standard list for the car?(Required)

Is the vehicle securely garaged at night?

Yes

No

Please provide further detail(Required)

eg, parked off street away from public view, parked under carport

Owner(s) and drivers’ history

In the last 5 years have you or any person likely to drive this car

Had:

a claim, accident or car stolen and/or burnt?

Yes

No

How Many Incidents(Required)

Please enter a number from 1 to 5.

Driver Name(Required)

First Last

Incident date(Required)

Month/year

Details (what happened?)(Required)

Example: Accident - rear ended another vehicle / other driver ran stop sign & struck rear left quarter. Vehicle stolen - recovered with damage / not located.

Your Insurer(Required)

Person at fault(Required)

Repair cost (if known)

Driver Name(Required)

First Last

Incident date(Required)

Month/year

Details (what happened?)(Required)

Example: Accident - rear ended another vehicle / other driver ran stop sign & struck rear left quarter. Vehicle stolen - recovered with damage / not located.

Your Insurer(Required)

Person at fault(Required)

Repair cost (if known)

Driver Name(Required)

First Last

Incident date(Required)

Month/year

Details (what happened?)(Required)

Example: Accident - rear ended another vehicle / other driver ran stop sign & struck rear left quarter. Vehicle stolen - recovered with damage / not located.

Your Insurer(Required)

Person at fault(Required)

Repair cost (if known)

Driver Name(Required)

First Last

Incident date(Required)

Month/year

Details (what happened?)(Required)

Example: Accident - rear ended another vehicle / other driver ran stop sign & struck rear left quarter. Vehicle stolen - recovered with damage / not located.

Your Insurer(Required)

Person at fault(Required)

Repair cost (if known)

Driver Name(Required)

First Last

Incident date(Required)

Month/year

Details (what happened?)(Required)

Example: Accident - rear ended another vehicle / other driver ran stop sign & struck rear left quarter. Vehicle stolen - recovered with damage / not located.

Your Insurer(Required)

Person at fault(Required)

Repair cost (if known)

insurance refused, declined or cancelled by an Insurer or special conditions imposed?

Yes

No

Date(Required)

DD slash MM slash YYYY

Insurer(Required)

Details(Required)

a drivers / motorcycle licence cancelled, suspended or endorsed?

Yes

No

Date(Required)

DD slash MM slash YYYY

Details(Required)

Been convicted or charged with:

drug use, driving under the influence or exceeding Prescribed Concentration of Alcohol?

Yes

No

Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: mid-range DUI

Penalty(Required)

Example: Alcohol lock / 3 months suspension

any driving offences or issued any speeding or traffic infringements?

Yes

No

How many?(Required)

Please enter a number from 0 to 5.

Driver Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: not wearing seat belt, using mobile phone while driving

Penalty(Required)

Example: 3 points, fine of $x

Driver Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: not wearing seat belt, using mobile phone while driving

Penalty(Required)

Example: 3 points, fine of $x

Driver Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: not wearing seat belt, using mobile phone while driving

Penalty(Required)

Example: 3 points, fine of $x

Driver Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: not wearing seat belt, using mobile phone while driving

Penalty(Required)

Example: 3 points, fine of $x

Driver Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: not wearing seat belt, using mobile phone while driving

Penalty(Required)

Example: 3 points, fine of $x

fraud, arson, theft or any other criminal act?

Yes

No

Name(Required)

First Last

Date(Required)

DD slash MM slash YYYY

Details(Required)

Example: explain the circumstance / charge

Penalty(Required)

Example: suspended sentence 2 years, probation, community service,

Suffered from any physical or mental disability that may affect your ability to drive (excluding eyesight corrected by lenses)?

Suffered from any physical or mental disability

Yes

No

Details(Required)

Have you held any car insurance in the past 12 months?

Held any car insurance in the past 12 months(Required)

Yes I have

No I have not

Please provide further details(Required)

Declaration

In signing this form, I acknowledge and understand the Terms & Conditions of the Fleet Manager Comprehensive Motor Car Insurance Policy.

I also declare that I have:

Received a copy of the Policy Disclosure Statement, Financial Services Guide and have had opportunity to review the Target Market Determination,
Read the information concerning the duty of disclosure and other important notices;
Answered every question fully & frankly;
Either completed this proposal form personally, or if it has been completed by someone else, I have checked that the questions have been fully and accurately answered.

Please be advised that the initial approval of this application is based on the information provided, and if additional information is required, you may be contacted by the Fleet Manager.

PLEASE NOTE: This application and any quote given are subject to full assessment on all the information provided by the applicant and are indicative to full assessment by the Insurer. Any failure to provide the correct information may give the Insurer the right to deny any claim.

I Agree(Required)

I Agree

Signature

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