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					motor vehicle insurance for privately owned non-commercial vehicles



           quotation request




                                       nlc insurance pty ltd abn 64 104 847 252
                                     finance fleet insurance salary packaging
                                                  Quotation Request

                             Upon completion of all details please return to nlc insurance



  DETAILS OF INTENDED INSURED

Name                                                                                              Date of Birth

                                                                                                             /       /

Employer                                                                                          Current Rating



Postal Address



                                                                                                    Postcode

Home Address



                                                                                                    Postcode

Business Telephone                          Home Telephone                            Mobile



Email




  VEHICLE DETAILS

Year                             Make                           Model                             Registration No.



Sum Insured (Current)            (Market Value)                 Financier



Purchase Price                   Approx Purchase Date           Postcode where the vehicle is garaged

                                             /      /

No claims Bonus Protection Required (Only available to drivers holding a current rating 1 /60%)

Yes                   No

Is the vehicle currently under lease with nlc?           If YES please confirm financier

Yes                   No

Current Insurer                                                                                   Expiry Date

                                                                                                             /       /



                                                                                                       Continued overleaf...

                                                                                      nlc insurance pty ltd abn 64 104 847 252
                                                    Quotation Request

                               Upon completion of all details please return to nlc insurance



 CLAIMS / DRIVING HISTORY

During the last five years have you or any person who may drive the vehicle:
Had any accident, fire or theft involving a motor vehicle?                                                                    Yes   No

Had their driver licence cancelled, suspended or endorsed?                                                                   Yes   No

Had a conviction for driving under the influence of alcohol?                                                                  Yes   No

Had any insurance declined, cancelled, renewal refused or had special terms, conditions or excess imposed on them?           Yes   No

Had more than one motor vehicle accident or claim in the last 2 years?                                                       Yes   No

Been criminally conviction for fraud, theft, drugs, actual or threatened damage to property or dishonesty of any kind?       Yes   No



If YES to any of the above, please give details:




                                        When complete, please forward the report to:
                                                  nlc insurance pty ltd
                                                    Locked Bag 4014
                                              South Melbourne Victoria 3205
                                                   Fax (03) 8699 7198



Office Use Only
Nvic No.                                                                 Car Desc No.

Date Quoted                                    /            /            Date Forwarded to Client                        /    /

Base Premium                        $                                    Stamp Duty                          $

Broker Fee                          $                                    Total Premium (Ex GST)              $

Total Premium (Inc GST)             $




                                                                                                nlc insurance pty ltd abn 64 104 847 252

				
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