Commercial Motor Vehicle Insurance (QLD)

Client Code:*

Name of person completing questionnaire:*

Insured Name:*

1. If you Hire-In Plant or Vehicles (Including Trailers), please advise the estimated maximum duration of each hire and also the highest valued item.*

2. If not already provided in your Policy are you interested in excess free windscreen cover for an additional premium?*

Yes
No

3. If available, are you interested in covering the hire costs for a similar vehicle following an accident?*

Yes
No

4. Are there any changes in your business activities/operations?*

Yes
No

If YES, please advise full details

Driver Disclosures:

5. Please provide details of any person under 25years of age or with less than two (2) years driving experience, that may drive or operate any of the insured units:*

6. Details of any Motor Insurance and/or claims refused and/or cancelled and/or imposed special terms in the last five (5) years:*

7. To the best of your knowledge, details of any convictions for driving under the influence of alcohol or drugs (DUI) and/or exceeding the prescribed content of alcohol (PCA) in the last three (3) years:*

8. To the best of your knowledge, have any employed drivers had a licence suspended or cancelled in the last five (5) years?*

Yes
No

If Yes, please provide details:

9. To the best of your knowledge, have any employed drivers been convicted of a total of more than two (2) traffic offences (excluding parking) in the last three (3) years?*

Yes
No

If Yes, please provide details:

Claims

10. Details of any claims that have occurred, but have not yet been reported*

11. After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to claims in the future.*

All changes or inclusions of any sort or type, including limits or sums insured shown, will take effect from the policy's expiry date unless you request otherwise.

Information we have provided to Sarina Insurance Brokers, is to the best of our knowledge correct. Please type your name below:*

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Commercial Motor Vehicle Insurance (QLD)

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