Fleet Motor Vehicle Insurance


Thank you for considering our on-line fleet motor vehicle insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right fleet motor vehicle insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


Schedule of Vehicles
1. Please ensure your Proposed Sum Insured represents the current market value
Item Make & Model Year Body Type Reg. No. Eng/Chassis Proposed sum
Insured		 Date & Purcase
Cost
1.
2.
3.
4.
2a. Are any of the vehicles LP Gas Converted?
Yes No
If yes, please provide details:
2b. If yes, has a standards specifications Certificate been issued?
Yes No
2c. Have any of the vehicles proposed been modified, altered or varied from the maker's standard vehicle production?
Yes No
If yes, please describe:
Vehicle Accessories
3a. Do you require cover for the following? Values of accessories which are nominated are to be in the Sum Insured
Tarps
Yes No
Gates
Yes No
Dogs
Yes No
Chains
Yes No
3b. Non-removable items (eg. fixed phone, agitator hiab crane)
Item $
Item $
Item $
Item $
3c. Removable items (eg. mobile phone, tv's, fridges)
Item $
Item $
Item $
Item $
Note: Removable Items are not covered unless agreed in writing.
No Claim Bonus Entitlement
4a. Previous Insurer:
4b. Name of policy owner:
4c. No. of Claims free years insured:
4d. Policy number:
4e. Vehicle insured:
4f. No Claims Bonus entitlement: %
Note: Written evidence from an authorised insurer must be supplied or faxed. If we cannot verify your No Claims Bonus, full premium will apply or the Period of your insurance may be reduced
Vehicle Operations
5a. Is the vehicle presently insured with another insurer?
Yes No
5b. Is the vehicle owned or registered by anyone other than yourself?
Yes No
5c. Is the vehicle lent out or leased out, or control assigned to any other party?
Yes No
If yes, to any of the above, please supply details:
5d. Is the vehicle in a safe, roadworthy, undamaged condition?
Yes No
5e. Base of operation:
5f. State the radius required: kms
5g. What is your furthermost normal destination (eg. town, city):
5h. Nature of good carried (eg. general containers):
5i. Will Dangerous Goods be carried (ie. explosives, acids, flammables or chemicals)?
Yes No
If yes, please indicate:
Class Type:
Substance Carried:
Estimate of quantity carried any one load:
Proposer's History
6. Has the proposer of this insurance ever had Insurance Company
6a. Refuse to accept any Insurance proposal?
Yes No
6b. Refuse to renew any policy?
Yes No
6c. Refuse a claim under any policy?
Yes No
6d. Cancel or terminate any policy?
Yes No
6e. Required an increased premium under any policy?
Yes No
6f. Impose special conditions under any policy?
Yes No
7. Have you any physical or mental defects or infirmity?
Yes No
If yes, please provide details:
8. Have you ever been charged with an offence in connection with the care, control, management or use of a motor vehicle or had a driving licence suspended, endorsed or cancelled?
Yes No
If yes, please provide details:
9. What is your date of birth (dd/mm/yyyy)?
10. How many years have you been operating this class of vehicle?
11. During the last 10 years, have you had any vehicle accidents, fire, thefts, hail or flood damage, Malicious damage, liabilities or any other losses?
Yes No
If yes, please complete below. 'Known to Company' not an acceptable answer.
Date of Event Driver Insurer Details Own Damage Other
Employed Driver
12. Shall any person other than the insured by in charge of the vehicle(s)?
Yes No
If yes, the applicable drivers questionnaire must be completed, failing which an additional undeclared driver excess shall be applied.
13. Type of Loan
Lease
P/Loan
Mortgage
Other


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: