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Mobile Plant & Machinery, Truck, Motor Vehicle, Trailer, Public Liability and Tools

Please complete the following information and submit this form to obtain an insurance quotation.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

Please click here for further information on machinery, plant and equipment insurance.

Click on one of the following links if you would like the quotation to include other types of cover such as;
- Public Liability Insurance
- Trades Insurance

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INSURED

Insured Full Name:*
Business Name (if applies):
ABN:

INSURANCE DETAILS

Mobile Plant & Machinery, Truck, Motor Vehicle, Trailers

IMPORTANT: Un-Registered Items
Cover will exclude damage to third party property or third party injury caused by the item / machine Cover Recommendation Obtain a Public Liability Insurance Policy

Cover Required?*

Public Liability

(For amounts you become legally liable to pay as compensation for Personal injury or Property Damage as a direct result of an occurrence happening in connection with your business - subject to the Insurers PDS/Policy Wording)

Liability Cover Required?*

Fully describe all the products and/or services your business provides:*
Sum Insured Required*
Do you employ sub / contractors*	Yes No
Annual Payments to sub / contractors*	$
Do you use labour hire*	Yes No
Annual payments to labour hire*	$
Does the business import &/or export?*
Please provide details (inc Country, Products, etc)*
Total Number of Staff*
Annual Business Turnover*	$

Do your operations include any of the following:
work at airports, railway, oilrigs, gas rigs, oil refineries, chemical refineries, mines or quarries, ship yards? work with/on cooling towers, alarm systems or mainframe computers? boilers and/or compressors which require Government certificates? manufacture, distribution, storage, transportation, of chemicals or other toxic or harmful matter? use or storage of explosives? provide any advice, design or professional services, whether or not a fee is charged for such advice, design or professional service? conduct any welding?
Yes No
If "YES" to any of the above, please provide details*

Tools

(Covers the insured property anywhere in Australia - subject to the Insurers PDS/Policy Wording)

Portable Items Cover Required?*

Total Sum Insured of all portable items*	$
List items value over $1,000 and include the item value*

PREVIOUS INSURANCE

Are you currently insured?*

Please provide the date your existing policy expires*
Please provide the name of the Insurer*
Please provide the Insurer name*

Have you, or anyone who will operate any of your Vehicles or Machinery:

1. Ever suffered any losses or claims in the last 5 years?*	Yes No
Please provide: * - Date of claims/s - Insurance Company's Name - Amount Claimed - Description of the claim/s

2. Had any motor insurance policies or claims refused or cancelled or special terms imposed in the last 5 years?*	Yes No
3. Ever been charged or convicted of any criminal offence or declared bankrupt, including driving under the influence of alcohol or drugs (DUI), had a licence suspended or cancelled or been convicted of a total of more than 2 traffic offences (excluding parking) in the last 5 Years?*	Yes No
4. Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance? *	Yes No
If "YES" to questions 2 - 4 above, please provide details*

CONTACT DETAILS

First Name*
Surname*
Phone No*
Street Number/Name*
Suburb*
Post Code*
Email Address*
How did you find us*
If other, please provide details*
Please provide machinery dealer name*

Comments

* Mandatory Fields
Thank you for completing our online form.
We will endevour to contact you with your insurance details soon.

We may need to contact you to obtain additional information to provide you with an insurance quotation.
Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.
All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.
We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.

Item 1

Year *
Make *
Model *
Type *	e.g. excavator, sedan, rigid truck etc
If truck, what body type *
	Add vehicle attachment

Type of Cover*
Driver / Operator Full Name:*
Driver / Operator Date Of Birth:*	/ /
Garaging / Storage Address*
City/Town*
Post Code*

Value, including attachments *
Is this item registered: *	Yes No
Provide Reg No.*
GVM*

Confirm the type of security the vehicle / truck / machinery / plant / trailer is fitted with?*

Other security details

Attachment 1

Detail:

Value:

Additional Driver / Operator 1
X
Driver / Operator Full Name:*
Driver / Operator Date Of Birth:*	/ /

Number of Employees*
How many years experience do you have operating this type of machinery or similar equipment?*
Number of years operating this business*
Do you currently (or recently) have truck insurance? (years held)*
Do you currently (or recently) have machinery insurance? (years held)*
Is the vehicle / truck / machinery / plant / trailer, involved in work at locations above the 26th degree parallel in Western Australia or Northern Territory?*	Yes No
Do you allow sub-contractors to drive or operate your vehicle / truck / machinery / plant / trailer?*	Yes No
If "YES" to any of the above, please provide specific details:*

Is any of the items being insured used or expected to be used in any of the following activities:
On, in, over or under a permanent body of water? Sand or beach operations? A tidal zone? Floating platforms or barges? Irrigation systems, canals, reservoir, filled dam/s or siphon work? Demolition greater than 15m in height? Exploration, dangerous gases, work in oil? Chemical/ petrochemical plants or other dangerous occupations? Underground works tunnelling, shafts or galleries excavation deeper than 10m? Blasting or explosives? Directional drilling or boring greater than 1m in diameter? Airport/aircraft landing area, railways, tramlines or on road works or bridges?
Yes No
If "YES" to any of the above, please provide specific details:*

Are these item/s used for business or private use?*
What is your occupation?*
Fully describe what the vehicle / truck / machinery / plant / trailer, will be used for *