Tell us about Yourself
|
| Are you currently, or have you ever been a Famous Insurance Client |
{:36} |
| How did you hear about Famous Insurance Brokers |
{:37} |
| When would you like your insurance policy to begin |
{:38} |
| Insured's Name |
{:39.3} {:39.6} |
| Insured's Contact Number |
{:40} |
| Insured's Email Address |
{:41} |
| Age of the Main Rider |
{:42} |
Tell Us about Your Special Ride
|
| Type of Insurance Cover required |
{:45} |
| Cover Type |
{:1} |
| Salvage Rights |
{:3} |
| Hire Car |
{:5} |
| Choice of your Own Repairer |
{:6} |
| Riding Apparel |
{:7} |
| State |
{:8} |
| Is the Bike registered? |
{:9} |
| Registration number |
{:10} |
| VIN Number or Engine Number |
{:11} |
| Year of Manufacture |
{:53} |
| Make |
{:54} |
| Model |
{:55} |
| Description/Model Name/Variant/Spec/Badge |
{:56} |
| Series |
{:57} |
| Engine Capacity |
{:18} |
| Security System on the bike |
{:19} |
| Please list - if selected "Other" |
{:59} |
| Value of Bike (including modifications and accessories)) |
{:20} |
| Is the bike under finance |
{:21} |
| (If yes to above) Finance Company |
{:22} |
| Bike Use |
{:23} |
| Frequency of use |
{:24} |
| Purchase Price |
{:25} |
| Purchase Year |
{:50} |
| Any modifications on the bike |
{:27} |
| Modification / Accessory |
{:28} |
| Existing Damaged or a Previous Write Off |
{:29} |
| Provide details |
{:30} |
| Will the Bike be ridden by anyone under the age of 25 years old |
{:31} |
| Will the bike be driven by anyone under the age of 25 years old |
{:33} |
| How is the bike parked over night |
{:32} |
| Please list - if selected "Other" |
{:33} |
| Overnight Parking Address |
{:34.1}, {:34.3}, {:34.4}, {:34.5}, {:34.6} |
Tell us about Your Riders
|
| Rider's Name |
{:66.3} {:66.6} |
| Rider's Contact Number |
{:67} |
| Rider's Date of Birth |
{:68} |
| Rider's Gender |
{:69} |
| Number of motor accidents, claims / losses (regardless of fault), thefts (including attempted thefts), malicious damage, damage whilst parked and weather (hail) damage within the last 5 years |
{:70} |
| Please list all traffic offences |
{:71} |
| All traffic offences, licence suspensions, good behaviour periods, or special terms imposed within the last 5 years |
{:72} |
| All criminal convictions, bankruptcies, claims declined, and/or declined/cancelled insurance policies (any type) within the last 5 years for Driver and/or Insured |
{:73} |
| Type of License Held by the driver |
{:74} |
| Number of years Rider has held an Australian License |
{:75} |
| Would you like to add an additional rider? |
{:76} |
| Additional Rider's Name |
{:78.3} {:78.6} |
| Additional Rider's Contact Number |
{:79} |
| Additional Rider's Date of Birth |
{:80} |
| Additional Rider's Gender |
{:81} |
| Additional Rider's - Number of motor accidents, claims / losses (regardless of fault), thefts (including attempted thefts), malicious damage, damage whilst parked and weather (hail) damage within the last 5 years |
{:82} |
| Additional Rider's - Please list all traffic offences |
{:83} |
| Additional Rider's - All traffic offences, licence suspensions, good behaviour periods, or special terms imposed within the last 5 years |
{:84} |
| Additional Rider's - All criminal convictions, bankruptcies, claims declined, and/or declined/cancelled insurance policies (any type) within the last 5 years for Driver and/or Insured |
{:85} |
| Additional Rider's - Type of License Held by the driver |
{:86} |
| Additional Rider's - Number of years Rider has held an Australian License |
{:87} |
