JCI | Request for Mobile Coffee Van/Trailer Quote

Contact Details

Email Address:

Phone Number/Mobile:

Business Details

Business Structure:

Company or Insured Name:

Trading As:

ABN No.:

Registered for GST:

Yes

No

Mailing Address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Situation at Risk

Business operated from

Business Address

Is the business address the same as mailing address ?

Yes

No

How long has the business been operating?

Annual Gross Turnover

Number of Staff Full Time

Part Time

Vehicle Details

Vehicle Details #1

Where is the vehicle parked?

Vehicle Type

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Registration

VIN / Chassis Number

Engine Number

Transmission

Motor vehicle cover details

Sum Insured (including fit out and equipment)

Date of Birth of Regular Driver

Current No Claim Bonus

Anti-Theft Devices

Interested Parties

Yes

No

Windscreen Excess Waiver

Yes

No

Insurance Options

Insurance History

In the last 5 years have you

i) had insurance refused, cancelled, declined or special terms imposed?

Yes

No

ii) been declared bankrupt, placed in liquidation, receivership or voluntary administration?

Yes

No

iii) been convicted of or had any fines imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?

Yes

No

Claim History

In the last 5 years have you made any motor vehicle claims?

Yes

No

	Insurer	Claim date	Type of Claim	Amount Paid	At Fault	Finalized	Description

In the last 5 years have you hade any other claims related to the covers selected i.e. Machinery Breakdown, Business Interruption, Public Liability, etc.?

Yes

No

	Insurer	Claim date	Type of Claim	Amount Paid	At Fault	Finalized	Description