TCIS Insurance Brokers Pty Ltd
Four Wheel Drive Motor Vehicle Insurance Application

Please use your TAB key to advance through the application form. Click the submit button at
the bottom of the page to email your application to our team. Please complete all fields unless
otherwise indicated.

Section 1: General Details

Registered Owner(s):
Telephone Details: Mobile: Home: Work: Fax:
Email Address :
Best Contact Point:
Name of 4WD Club (if member) :
Date of Birth of Registered Owner 1: Date of Birth of Registered Owner 2 (if applicable):
Driving Experience of Registered Owner 1: yrs Driving Experience of Registered Owner 2 (if applicable): yrs

Section 2: Four Wheel Drive Motor Vehicle Details

Registration No: Year of Manufacture:
Make and Model of Vehicle (full description):
Turbo: YES NO Petrol Diesel Cylinders:
Current Vehicle Value: $ + Current Options & Accessories: $ = Total Current Sum Insured: $
Current Insurer: No claims Rating or Years:
Vehicle under Finance? YES NO Finance Type & Financier:

Do you wish to pay an additional premium to:

1. Protect your no claim bonus
(only applies to rating 1 (60%) No Claim Bonus)

2. Include excess free windscreen cover:

 

YES NO

YES NO

What percentage is the vehicle used for off road use/activities? %
Do you enter any competitions or time trials? YES NO

Period of Insurance Required: Commencing: / / Expiring: / /
Has, or is any regular driver/s:
(a) Under 21 years of age? YES NO
(b) Lost their licence in the last 5 years? YES NO
(c) Had motor insurance declined, cancelled or renewal refused? YES NO
(d) Had any motor claims or other losses in the last 5 years? YES NO
(e) Had any insurer require special terms? YES NO
(f) Used/ing the vehicle in any business or commercial activities? YES NO
(g) Been charged, convicted or penalised for any motoring offences? YES NO
(h) Been charged or convicted of any criminal offences in the last 10 years? YES NO
(i) Are there any exceptional circumstances relating to the risk, which may affect our decision to insure you ? YES NO

If yes to any of the above, please provide details:
Please list all motor accessories, options and modifications:
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $
Item: Approx. Age: Approx. Value: $

Please give details of those other people you know will be driving the vehicle. This DOES NOT include the registered owners/drivers listed already.
Driver 3 Mr Mrs Miss Ms Other

Given Name(s) Use Block Letters
Surname Date of Birth
Years of Driving
Percentage of Total Driving (of insured vehicle)

Driver 4 Mr Mrs Miss Ms Other

Given Name(s) Use Block Letters
Surname Date of Birth
Years of Driving
Percentage of Total Driving (of insured vehicle)


Section 3: Vehicle Security Details

Suburb and Postcode where the vehicle will be kept overnight: Suburb: Postcode:
Vehicle will be parked in: Garage: Carport: Driveway:

Is your vehicle is fitted with a PASSIVE ARMING IMMOBILISER which disables the fuel pump, ignition and starter motor?
(passive arming immobiliser means the system automatically sets itself upon removal of the ignition key)

YES NO

If no, please provide details of what security device you do have and how the system is activated or method of operation.

IMPORTANT MATTERS REFERRED TO IN THE INSURANCE CONTRACTS ACT 1984

1. YOUR DUTY OF DISCLOSURE

Before you enter into a Contract of General Insurance with us, you have a duty under the Insurance Contracts Act 1984, to disclose to us every matter you know, or could be reasonably expected to know, that is relevant to our decision whether to accept the risk of the insurance an, if so, on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate your insurance.

Your duty does not, however, require disclosure of matters:

(a) that diminish the risk to be undertaken by us;
(b) that are of common knowledge
(c) that we know, or in the ordinary course of business, ought to know;
(d) as to which compliance with your duty is waived by us.

2. NON-DISCLOSURE

(a) The statements in the Application Form are true.
(b) I/We have disclosed all matters of which, to my/our knowledge, you should be aware.
(c) No Insurance Company has ever cancelled, declined, or refused to renew, or imposed special terms or conditions, on any policy held by me/us.
(d) The I/We agree to accept the terms, exclusions, conditions and limitations of the Insurance Contract.

No Claim Bonus must be proved prior to cover placement. This may be faxed to us on 08 8278 8555 if cover is urgently required. Original must be posted, accompanied by payment to: PO BOX 425, Blackwood, SA 5051