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Waste Truck Quote

Your Details

Full name: (incl Title) *

Contact telephone number: *

Date of Birth *

Email address: *

Contacting You

Preferred contact method: *

Preferred contact time: *

How did you hear about us? *

Duty of Disclosure

Ever had any insurance cancelled or declined or special terms imposed?

YesNo

Ever been charged or convicted of any criminal offence or declared bankrupt?

YesNo

Have you had any accidents or claims in the last 5 years?

YesNo

Vehicle Details

Type of Cover:

Postcode where vehicle is kept overnight:

Occupation:

Year of Manufacture:

Make & Model:

(i.e: Volvo FE6)

Body Type:

(i.e: Compactor, hook lift)

Cylinders:

Is the vehicle turbo charged?

YesNo

Transmission:

Security. Please detail

Registration:

Value

Agreed Value (enter value if Agreed Value is selected)

Any Accessories or Modifications. Please detail (Please include any companies body’s and values)

Finance:

Any other specific cover required. Please detail

Public Liability

Annual Gross Turnover

Limit of Liability:

Radius of Operation:

Carrying Capacity:

Driver Details

Name of Driver:

Date of Birth of Driver:

No. of years Licence held:

Claims Experience

Please provide full details of any claims made and/or losses suffered under previous Commercial Motor Insurance during the past 5 years (whether or not a claim was made):

General Questions

Please use this box to provide any further information that may be relevant to your Commercial Motor Insurance policy:

Current Commercial Motor Insurance provider:

Renewal date of existing insurance/date cover to start (as applicable):

Current Commercial Motor Insurance premium:

Are you an existing Gale Insurance customer? *

YesNo

Gale Insurance Brokers trading name of Gale Insurance Pty Ltd. We would like to contact you from time to time about products and services (or with news, offers and promotions) that we feel may be of interest to you. By providing us with your contact details, you consent to being contacted by these methods for these purposes.

Please tick the box if you prefer to not to receive marketing communications from us by post or telephone.

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