Lend Shore Finance.CAR INSURANCE QUOTE REQUEST Name * First Name Last Name Email * Phone (###) ### #### Date of birth * MM DD YYYY Gender Female Male Other YOUR CAR Please include make, model & year Do you have any of the following accessories or modifications? * Custom or Specialised Paint , Nitro or Hydrogen Fuel(after market), Petrol Turbo or Supercharger (fitted after market), Roll Bar / Roll Cage / Racing Harness No Yes Unsure Is it in roadworthy condition? Yes No Is your car financed? Yes No What is your car primarily used for? Private Business Ridesharing On average, how many kilometres do you drive in a year? * Less than 5,000km Up to 10,000km Up to 15,000km Up to 20,000km More than 20,000km Who is your current or most recent insurance provider?This question is required. AAMI Allianz GIO NRMA RACQ RACV Suncorp Youi Budget Direct OTHER Not previously insured Is the car driven three or more weekdays, on average, between the following peak times? 7:30am - 9:30am and/or 3pm - 6:30pm Yes No In the last 3 years has the main driver had any car related claims, driver licence suspensions, cancellations, disqualifications or restrictions? Yes No How many days a week on average is the car used for trips to work or study? 0 (I work/study however do not require my car to commute) 1-2 Days 3-4 Days 5+ Days I do not work or study Address where your car is usually kept overnight: * Address 1 Address 2 City State/Province Zip/Postal Code Country On weekdays, where is the car usually parked during the day: Only complete if different from previous address provided Address 1 Address 2 City State/Province Zip/Postal Code Country ADDITIONAL DRIVERS Please list everyone (except learner drivers) who will drive this car more than once during the period of insurance, whether that's regularly or only occasionally. Your premium will be affected by the age, gender and driving history of your listed drivers. Suncorp is obligated to insure all drivers correctly. Failing to tell us about a repeat driver could result in your claim being reduced or not paid, a higher claim excess, or your policy being cancelled. How many additional drivers would you like listed on this policy? 0 1 2 3 4 5+ If yes above please list each person below In the last 3 years, have you or anyone to be insured under this policy had any: Insurance policy declined or cancelled, renewal declined, special terms imposed, or claim refused? Yes No In the last 3 years, have you or anyone to be insured under this policy committed any criminal act in relation to:This question is required. fraud, theft, burglary, drugs, arson, or criminal, malicious, or wilful damage? Yes No EXCESS An excess is the amount you have to pay for each incident when you make a claim. Depending on the circumstances, you might have to pay more than one type of excess when you claim. The amounts and types of excess are shown on your certificate of insurance. What excess amount would you like? $700 $800 $900 $1100 $1300 $1600 You may qualify for our 15% multi-policy discount. Do you currently have two or more of the following eligible Suncorp Insurance policies? Car, QLD CTP, Home (Building), Contents, Other policies (landlord, motorcycle, car trailer, caravan, boat and motorhome) Yes No Unsure How would you like to cover your car? Fixed amount Market Value Would you like Suncorp roadside assistance? Yes No Would you like windscreen & window glass cover? Yes No Would you like a hire car after an event up to 21 days? Yes No When would you like your policy to start? MM DD YYYY Thank you!
