CONTACT US

Murdoch InsureInvest Pty Ltd
127 Swanport Road
Murray BridgeSA 5253
P: (08) 8532 3200
F: (08) 8531 1511
EMAIL

AFSL 247118
ABN 99 105 567 995
Current FSG

Motor Insurance

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Name*:

Email*:

Contact Number:

Existing Client:

YesNo

Current Insurer:

Current No Claim Bonus:

Vehicle Details

Year of Manufacture:

Vehicle Make:

Vehicle Model:

Model Variant:

Body Type:

Transmission:

Fuel Type:

PetrolDieselLPG

Non Standard Accessories:

Vehicle Modified:

Yes No

If Yes, please specify:

Aftermarket Security:

NoneImmobiliserAlarmImmobiliser & Alarm

Type of Cover:

Type of Use:

PrivateBusinessBoth

Registration Number:

Driver 1

Name:

Date of Birth:

Year Licence obtained:

Owner of vehicle:

YesNo

Driver 2

Name:

Date of Birth:

Year Licence obtained:

Owner of vehicle:

YesNo

Questions for all Drivers - In the last 5 years have you had

Any motor claims in last 5 years?:

YesNo

Insurance declined, or special conditions imposed:

YesNo

Licence Suspended or Cancelled:

YesNo

Any Criminal Convictions:

YesNo

Any Motoring Offences:

YesNo

If Yes to any of the above, please specify:

Verification:

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