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Motor Vehicle _Private Use_ Needs Analysis Form

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Motor Vehicle _Private Use_ Needs Analysis Form Powered By Docstoc
					                                  Motor Vehicle Insurance
                             Insurance for Motor Vehicle and Legal Liability

Client Contact Details

Client Name:                                    Client Code:
(Remember to provide full insured details)


Mailing Address:

Contact Phone No.:                              Contact Fax:

Email Address:

Referral Source:              - Select Here -

BUYING MOTIVES?
To enable us to provide you with the most appropriate insurance product to meet your requirements we
need to ascertain what you are looking for when you are considering your motor vehicle insurance:

            The cheapest policy available as features and benefits do not concern you
            The best cover available so I am covered for as many things as possible
            Combination cheap price & a broad policy making sure of “value for money”
            I want to be able to contact my broker as relationship is important to me
            I want someone to look after any claims that occur & assist with the process

Have you had any motor vehicle accidents or made an insurance claim(s)                  Yes           No
involving a motor vehicle in the past 5 years?
If you answer Yes, please provide details of the accident or claim.

Have you had any fines, penalties or convictions in connection with the use of          Yes           No
any vehicle during the past 5 years? This should include any speed camera or red
light camera offences recorded against you.
If you answer Yes, please provide details of the convictions received.

In which town / suburb is the vehicle usually parked at night?
In which year was the vehicle manufactured?
What is the make (manufacturer) of the vehicle?
What is the model of the vehicle?
Please provide a full description of the vehicle including model identification numbers.

What is the registration number of the vehicle?

What is the engine type of the vehicle?

What is the current value of the vehicle? This is the current retail value including accessories fitted to
the vehicle.
 $




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Is the vehicle fitted with accessories that are not standard for the make and          Yes            No
model?



If Yes, list the accessories and their value:
Engine modification:        $                         Music system:                $

Transmission                $                         Anti-theft device:           $
modification:
Body modification:          $                         Special paint work:          $

Suspension modification: $                            Car phone                    $

Rally pack:                 $                         CB or two-way radio:         $

Special wheels:             $                         Tow bar:                     $

Air conditioning:           $                         LPG conversion:              $

Sun roof:                   $                         Other modifications -
                                                      please list:

In the event of a total loss, insurance can be arranged to pay you an amount                 Market Value
equal to the market value of the vehicle or an agreed value. Please indicate the
type of policy you would prefer:                                                          Agreed Value

Is the vehicle designed for the purpose of carrying goods?                             Yes            No

How is the vehicle usually "housed" at night?
                                                                                       - Select Here -
If Other, please specify:

Is the vehicle financed by a Third Party?                                              Yes            No

If Yes, please indicate the type of finance arrangement:                               - Select Here -
Other:

What is the name of the finance company?

What is the date of birth of the person who usually drives the vehicle?

What is the gender of the person who usually drives the vehicle?                   Male           Female
                                                                                       Yes            No
Is the vehicle currently insured by you?
Are you entitled to a no claim bonus?                                                  Yes            No

If Yes, how much no claim bonus are you entitled to? A 10% no claim bonus is
allowed for each year, up to a maximum of 6 years, that you do not a claim on          - Select Here -
any insurance policy covering vehicles.

Note: You will be required to substantiate your no claim bonus if you accept our
quote and instruct us to arrange the insurance.




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How many years has the person, who usually drives the vehicle, held an
                                                                                                     years
Australian drivers licence?
Other than the person who usually drives the vehicle, is it likely other people will       Yes           No
drive the vehicle?

If Yes, list the names(s) of the people, their date(s) of birth and the percentage of time they are likely to
use the vehicle:

Name:            DOB:            % Use:

Name:            DOB:            % Use:

Name:            DOB:            % Use:

Name:            DOB:            % Use:

If you are on the maximum no claim bonus, in the event that you make a "driver             Yes           No
at fault" claim during the insurance period, you can protect your maximum no
claim bonus by the payment of an additional premium. Please indicate if you
would like the quotation to include no claim bonus protection.

Is this quote for the renewal of an existing insurance policy?                             Yes           No

If yes, please advise:

Name of the current insurer:
Policy number:
Expiry date of the current policy:

Is the vehicle fitted with security in addition to that provided by the                    Yes           No
manufacturer?
If Yes, indicate the additional security installed:
                                                                                           - Select Here -
Other:

What is the approximate distance the vehicle travels per year?
                                                                                           - Select Here -

This Needs Analysis was prepared by                                 on        /        /         .




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                                   OFFICE USE ONLY
WHAT ADVICE ARE YOU GIVING?
To enable us to provide you with the appropriate insurance product to meet your circumstances,
financial objectives and needs we require certain information from you. In doing so, you have

         Agreed to provide the following information about your circumstances, objectives and needs.
         Asked that only certain needs were to be considered as stated.
         Chosen not to complete the Needs Analysis or did not provide all of the information requested.
         Asked that information previously collected be used including amendments agreed. The
         information remains relevant and up to date.
         General Advice Only.

COMPLIANCE
Have you advised the client of the PRIVACY ACT?                                    Yes       No
Have you advised the client of the DUTY OF DISCLOSURE?                             Yes       No
Have you advised or provided the client of our FINANCIAL SERVICES GUIDE?           Yes       No
Did you provide a PRODUCT DISCLOSURE STATEMENT (verbal or document)?               Yes       No
    If so what date was it provided?
                                                                                         /       /


Our firm will use this information to make certain recommendations to you so the
information provided must be specific and correct otherwise it could affect the outcome of
the advice we provide.




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