On-line Motor Car Insurance


Thank you for considering our on-line motor car 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 motor car / automotive 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.

For fleet vehicles, please click here
For a standard private vehicle, classic, modified, prestige, vintage or commercial vehicles please continue with this form


1. Motor car insurance policy type you are seeking (please select from list):
Policy options:
2a. Would you like to pay extra (approx. $35) to include one windscreen replacement per year?:
(which doesn't affect your No Claim Bonus)
2b. Would you like to pay extra (approx. $35) to include No Claim Bonus protection?:
(so you retain your NCB even if you have an accident which is your fault)
2c. If you are over 25 would you be happy to exclude drivers under 25 from using this vehicle?
2d. If you are over 25 would you be happy to restrict drivers to 2 named people only?
About the vehicle you wish to insure:
3a. Make:
3b. Model (e.g. Commodore):
3c. Type (e.g. Executive):
3d. Series (e.g. VT):
3e. Year:
3f. Body type:
3g. Engine capacity in litres:
3h. Turbo:
3i. Transmission:
Manual Automatic
3j. Metallic paint:
3k. Vehicle Colour:
3l. Accessories / modifications (please give details and value):
3m. Estimated value of vehicle: $ 
3n. Is the vehicle a private import?
Yes No
3o. Suburb in which the vehicle will be parked at night:
 Postcode:
3p. How will it be parked?
3q. Suburb in which the vehicle will be parked during the day:
 Postcode:
3r. How will it be parked?
3s. How often is the car used?:
3t. Approximate distance travelled per year (km):
3u. What purposes is the vehicle mainly used for?
3v. What is the ownership status of the vehicle?
3w. Do you have any car club memberships (give details)?
Security information about the vehicle:
4. Does the vehicle have any anti-theft equipment?
Yes No
If yes, please specify: Audible alarm only
Alarm & engine immobiliser
Lock tight deadlocking
Steering lock
Mobile tracking
Self arming immobiliser
Ignition kill switch
Other (please specify)  
Driver information:
5a. Date of birth of regular driver (DD/MM/YYYY):
5b.
M F
5c. Percentage of use: %
5d. Occupation of Regular driver:
5e. How long has this driver held a drivers licence? years
5f. Have you had any traffic offences, accidents, vehicles stolen, any other vehicle loss/damage and licence suspension or cancellation for the last 5 years?
Yes No
If yes please give full details:
5g. Are you entitled to a No Claim Bonus with your current insurer?
Yes No
If yes, please specify what rating:
5h. If you hold rating 1, how many years has it been since your last claim (enter 99 if you have never claimed):
Other Driver 1 information:
5i. Name of other driver:
5j. Date of birth of other driver (DD/MM/YYYY):
5k.
M F
5l. Percentage of use: %
5m. Rating of other driver:
5n. Years Licenced:
5o. Occupation of other driver:
5p. Have you had any traffic offences, accidents, vehicles stolen, any other vehicle loss/damage and licence suspension or cancellation for the last 5 years?
Yes No
If yes please give full details:
Other Driver 2 information:
5q. Name of other driver:
5r. Date of birth of other driver (DD/MM/YYYY):
5s.
M F
5t. Percentage of use: %
5u. Rating of other driver:
5v. Years Licenced:
5w. Occupation of other driver:
5x. Have you had any traffic offences, accidents, vehicles stolen, any other vehicle loss/damage and licence suspension or cancellation for the last 5 years?
Yes No
If yes please give full details:
Insurance history of the vehicle:
6a. Name of previous insurer:
6b. Due date of policy:
6c. Amount paid $:


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: