Name of Insured

First Name
Last Name
Drivers Date of Birth
Email
Phone

Vehicle to be Insured

Motor Vehicle Make & Model
Year Built
Registration Plate Number
Region of New Zealand in which the vehicle is based
Has this vehicle been reregistered	yes no
Previous registration if known
Has this vehicle had refurbishment	no partial full

Car Insurance

If the vehicle has been altered you must list the modifications to qualify for modified car insurance. Please list all non-standard features, modifications and accessories fitted to the vehicle.

Agreed value* of vehicle including accessories
*Noting agreed value must not exceed 25% above current market value. If possible provide security of value send copy of recent qualified valuation.

Insurance History

Have you had motor vehicle insurance in the last 5 years	yes no
Is your motor vehicle insurance still current	no partial full
Current insurance company
Have you had an motor vehicle insurance claim in the last five years	yes no
Please provide the years of all claims and details of what happened for each claim
Do you still have a full No Claim Bonus (NCB) on your current vehicle policy	yes no

Driving Convictions

Have you had been convicted of any driving offences in the last 5 years	yes no
What were the convictions for: Note: Speed camera tickets don't count.
When were the convictions

Other Convictions

Have you had been any criminal convictions of any kind	yes no
What were the convictions for:
Date of other convictions

Others

Do you put the car into car club rally events?	yes no
Are your events in the club family friendly rallies?	yes no
Are the events that you put your car into:
· competitive time trials?	yes no
· hill climbs?	yes no
· track events?	yes no
· on closed roads?	yes no
Do you put your car into Targa Events or the supporter event?	yes no
Are you a member of a car club that is a member of or an affiliated member of Motorsport New Zealand?	yes no
If you have any other points that relate to the running / ownership of your car, that you think we should know about before we provide a quote, please advise.

The insurance quotation will be based on the information which has been provided by you on this form. This form is purely to enable
the provider to understand the risk to be insured and to provide a quote. Please note that on acceptance of the quotation by you, there
will be a requirement to complete a proposal form which will request much of the information supplied on this form. On acceptance of
our quote a premium invoice will be used which will be due for payment within 30 days. The providers of the insurance will provide
premium payment options which will be disclosed on acceptance of the quote.