Motor Vehicle Quote

Tell us about Vehicle details.
Vehicle Registration Number*
Vehicle Year/Make/Model*
Accessories
Modifications
Transmission*
Type of Cover Requested*
- Comprehensive (Unlimited kms)
- Comprehensive ‘Limited Kilometres’ (Limited to 5,001-8,000 kms per year)
- Comprehensive ‘Low Kilometres’ (Limited to 0 – 5,000 kms per year)
Agreed Value*
What is your current/ preferred policy excess?**
Other*
Have you Purchased in Last 12 months?*
- Yes
- No
Vehicle Details
Purchase Price
Purchased Date
No Claim Bonus or Rating No*

Tell us more details about your vehicle.
Use of Vehicle*
Occupation*
Finance*
- Yes
- No
Financier*
Address where vehicle is left overnight*
Street Address Address Line 2 City State Postcode
Parked overnight in*
If Other*
Security Device Fitted?*
- Yes
- No
If yes, details of immobiliser or tracking system*
Drivers Details*
First Name Last Name % of Use Date of Birth (dd/mm/yyy)

Please ensure % of Use totals to 100% across all drivers.

1. Drivers less than 25 years of age not acceptable (30 in some cases).
2. Approved drivers must be licensed in Australia or New Zealand (provisional licenses excluded).
In the LAST THREE (3) YEARS have any of the drivers had any accidents, vehicles stolen or burnt, or any other losses involving a vehicle where an insurance claim has been made?*
- Yes
- No
Please provide details*
Driver Name Description of Loss Date of Loss Cost of Loss
In the LAST THREE (3) YEARS have any of the drivers committed any traffic offences which have resulted in a conviction or for which a penalty has been imposed or points lost?*
- Yes
- No
Please provide details:*
Driver Name Description of Offence Date Penalty Imposed If Speeding, kms over limit
How did you hear about Atia?*
Policy effective from*
DD slash MM slash YYYY
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Please provide some details for your vehicle quote.

First Name	Last Name	% of Use	Date of Birth (dd/mm/yyy)

Driver Name	Description of Loss	Date of Loss	Cost of Loss

Driver Name	Description of Offence	Date	Penalty Imposed	If Speeding, kms over limit