Bus, Hire Car & Taxi|Colonial Insurance

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Colonial Insurance Dictionary

Please complete and return the following form together with claims history for at least last 3 year on underwriters letterhead via email support@colonialinsurance.com.au or fax it to 02 9683 1775

Period of Insurance

From: *

To: *

(at 4.00pm local standard time)

Insured

Surname or Company Name: *

First Name(s): *

ABN Number: *

Email: *

Postal Address: *

State/ Post Code: *

Telephone mobile: *

Telephone home: *

Date of Birth (if applicable):

The Vehicle

Year Of Manufacture: *

Make: *

Model: *

Type of body: *

Registration Number: *

Engine Number: *

Vehicle Identification Number: *

Purchase Price: *

Date of Purchase: *

Finance Company Name (if any): *

Underwriting Information

Which town do you operate from?: *

For what purpose is your vehicle used? : *

Will the vehicle be used to carry Dangerous Goods?: *

Yes

Have you ever been convicted of a criminal offence or been declared bankrupt?: *

Yes

Expiry date of the registration for this vehicle?: *

Have you had any insurance declined or special terms imposed in the last 5 years? : *

Yes

Has the vehicle been modified from the manufacturer's specifications so that its performance is altered?: *

Yes

Has the vehicle been modified to incorporate special equipment?: *

Yes