REI - Car

Car Quotation Request

Text in Red = Required Fields

Owner Details

First Name:
Surname:
Phone:		Email:

Risk Details

Address of Risk:
Suburb:
State:
Postcode:
Do you wish to exclude all drivers under the age of 25?		Yes No
Are any drivers 70 year old or more?		Yes No
Please advise the details of the youngest driver who drives the vehicle at least 10% of the time
Name
Gender	Male Female	Date of Birth	(Eg.20/10/1974)
Is your vehicle used for private and/or business purposes
Year of Manufacture		(Eg. 2004)
Make of Vehicle		(Eg. Ford)
Model and Type of Vehicle		(Eg.Falcon XI 6 cylinder Manual Utility)
Please select any non-factory security devices that have been fitted to your vehicle
Alarm		Ignition Kill Switch/Immobiliser
Transmission Lock		Satellite Cellular Tracking System
Has your vehicle been modified in any way?		Yes No
What is the total value of any accessories that have been fitted to your car?		$
What type of cover do you require?
How many kilometres does your vehicle travel per year?
Where is your vehicle normally parked at night?
Suburb		State		Postcode
How is your vehicle normally parked at night?
How is your vehicle normally parked during the day?
What type of finance applies to your vehicle?

Cover Required

Is your vehicle to be insured for Market Value or Agreed Value?	Market Value Agreed Value
What is the sum insured on your vehicle?	$
What is your current No Claim Bonus?

Real Estate Agency Details

Name of Real Estate Agency that has referred you to Aon Personal Insurance
Situation Address of Real Estate Agency
Contact Name
Phone

Addtional Comments

General Comments (Incl. relevant information)