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Motor Vehicle Application Form  
The Applicant/s
Name(s) of the Registered Owner(s) of the Vehicle (Known as the Insured)
Given Name
Tax Status
Registered Business No  Yes ABN Taxable
Residential Address
State Postcode
Contact Numbers
Private Phone No. Business Phone No.
Period of Isurance
From To at 4 p.m
Driver Details
Give details of all known drivers of the vehicle (INCLUDING THE OWNER). An additional excess may apply to undeclared drivers. However, this additional excess will not apply if the if the driver is over 25 years of age and has not been convicted of driving under the influencce, or not had their licence suspended or cancelled in the five years prior to the date of loss.

The undeclared driver excess will not apply for vehicles described for Business Use or if the Faultless Excess clause if applicable.
Drivers' Name(s)
(main driver first)
Date of Birth Sex Years Licensed
in Aust.
% of use Does this person own another vehicle
Surename Given Name (s)
If more drivers are declared, please add a sheet with the relevant information. Please tell us if you wish at any time to declare additional drivers.
Vehicle Details
Year of Manufacture Make of Vehicle e.g Ford, BMW, Holden Model Details e.g. Falcon XT, 320i,VE, Omega Registration Number Body Style e.g. Sedan, Wagon etc. No. of Doors No. of Cylinders
Engine or V.I.N Number   Metalic Paint
Transmissin Auto/Manual   Air Bags  
Engine Capacity
Turbo or Super Charged  
Fuel Type: Diesel/Petrol      
Establishing the Vehicle Value
a) Date vehicle purchased
b) Price paid (excluding any trade-in or consumer credit insurance)
c) If the vehicle is imported, has it an Australian Compliance Plate?
Has the vehicle any existing damage, e.g. dents, scrathes, rust or hail?
if "Yes", give details

e) If there are any accessories (including options fitted by the dealer) thats are not standard features for the make and model of your vehicle then please describe each accessory and their value e.g. air-coniditioning, ABS, bull bars, sun roof, theft security system, driving lights, upgraded stereo system, mag wheels, solar tinting, luggage racks, tow pack, LPG conversion etc.

Description Current Value Description Current Value
Accessories Total
f) What do you estimate is the current market value (including accessories) of your vehicle/
Type of Cover
Comprehensive Market Value Third Party Property Damage
Comprehensive Agreed Value Third Party Fire & Theft
Comprehensive Essentials  
Note: These terms are explained in more detail in the Policy wording.
Vehicle Modification
Give details of any modifications from the manufacturer's standard vehicle e.g. body, suspension, engin, wheels, paintwork
Parking Details
a) Where is the vehicle parked at night?
Suburb/Town State Postcode
b) How is the vehicle parked during the night?
Garage/Security Parking Street Other
Use of Vehicle
Private Executive Business
Note: These terms are explained in more detail in the Policy wording.
Finance Details
Is the vehicle financed?
Type of finance? Lease Secured Finance Loans Unsecured Loan Hire Purchase
Name and address of finance provider
State Postcode
Varying The Excess
For vehicles insured under Comprehensive cover only.
You can have the Standard Excess waived for an extra premium, or increased for a reduction in premium.
If you want a variation, please tick one of the following :
Windscreen Excess Protection
Do you want to remove the excess on windscreens for an extra premium?
Hire Car Following an Accident
After Market Theft Security Systems
Only complete if not fitted as a "standard" factory item.
If a security system is installed that immobillises your vehicle by: a) custting power to the ignition or cuts the fuel line or b) has a "full metal jacket" on the steering column, we will allow a discount. However, an additional excess of $200 will apply if your vehicle is stolen and the security system was not active.
Name/model of security system
Is the security system in good working order and properly maintained?
Tick box(es) for those features that operates
Protection No Claim Discount
If you are insured for comprehensive and are entitled to Maximum No Claim Discount with no "at fault" claims for the last 3 years, you can protect your N.C.D. for one "at fault" claim, by payment for extra premium. Do you require this Cover?
No Claim Discount Entitlement
Name of Last or Current Insurer Policy Number Date of Expiry Type of cover Yrs Insured Bonus
Registration Number of Vehicle Insured Have you disposal of that vehicle?
Please attach proof of your current No Claim Discount entitlement e.g. current original renewal notice or letter from insurer.
Owner(s) And Drivers' History
In the last 5 years have you or any person likely to drive this vehicle
1. Had
a) a claim, accident or car stolen or burnt (even if not reported or not claimed from an insurer)?
b) insurance refused, declined or cancelled by an insurer or any special conditions imposed?
c) a drivers ormotorcycle licence cancelled, suspended or endorsed?
2. Been convicted or charged with:  
a) drug use, driving under the influence, or exceeding Prescribed Concentration of Alchohol?
b) any driving offences or issued any speeding or traffic infringements?
c) fraud, arson, theft or any other criminal act?
3. Suffered from any physical or mental disability (excluding eyesight corrected by lenses)?
If you answered "Yes" to any of the above questions please provide details below. If insufficient space, please attached sheet.  
Name of Driver Date of Incident Details of each Incident Your Insurer Person at Fault
Duty Of Disclosure

Under the Insurance Contracts Act 1984 (the Act); you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you and anyone else to be insured under the Policy and if so, on what terms.

  • You do not have to tell us about any matter
    - that deminishes the risk
    - that is of common knowledge
    - that we know or should know in the ordinary course of our business as an insurer, or
    - which we indicate we do not want to know.
  • If you do not tell us
    If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.

QBE includes information about how we manage your personal information in our Product Disclosure Statement and Policy booklets. You can obtain a copy of the QBE Privacy Policy Statement from our website www.qbe.com or cantact the Compliance Manager on 02 9375 4656 or email compliance.manager@qbe.com for further information.

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