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Vehicle year

Vehicle make and model

Vehicle value

Estimated annual mileage (in km's)

Vehicle location

Has the vehicle been modified?

Yes
No

Please provide details

Please provide clear details of where your vehicle is usually stored/ parked:

Please provide details:

All drivers of vehicles will be over 25 years of age and hold a current full drivers licence?

Yes
No

Please provide details including type of licence held (learner, restricted or full) and date of birth for any drivers under 25

In the last 5 years have you, or anyone else who will drive the vehicle, had any insurance claims, speeding tickets, loss of licence?

Yes
No

Please provide details e.g. provide approximate dates, claims cost etc.

In the last 5 years have you, or anyone else who will drive the vehicle, ever had any insurance cancelled, insurance renewal refused or had an insurance claim denied?

Yes
No

Please provide details:

Have you ever declared bankruptcy?

Yes
No

Please provide details:

Are there any criminal convictions (that are not covered by the Clean Slate Act) that you need to advise us of for yourself or any of the intended drivers?

Yes
No

Please provide details

Any other comments or feedback

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Principal driver's Date of Birth