Quote - Vehicle Insurance - NZ Police Association

First name *

Last name *

Member Name or QID *

Date of Birth *

Phone number *

Email *

Street number and name *

Suburb *

Town / City *

Postcode *

Select cover

Vehicle Registration

Vehicle type

Year *

Make *

Model *

CC rating *

Turbo *

No

Yes

If turbo, select type *

Immobiliser/Alarm

No

Yes

Sum Insured - (market value inc GST) *

Will anyone under 25 be driving? *

Yes

No

If no - do you want to exclude drivers under 25 years? You receive a discount for excluding all drivers under 25yrs, there is no cover while the vehicle is being used by anyone under 25. *

Yes

No

Full name of main driver *

Gender of main driver *

Female

Male

Main driver - date of birth *

Number of years main driver has had a full NZ drivers licence *

In the last 5 years has the main driver had any incidents involving damage or theft of a vehicle?

Yes

No

Incident 1 - Year

Incident 1 - Incident type

Incident 2 - Year

Incident 2 - Incident type

Incident 3 - Year

Incident 3 - Incident type

Incident 4 - Year

Incident 4 - Incident type

Is your vehicle used for business or have any modifications, left hand drive or have any non-factory equipment? *

No

Yes

Year caravan made

Model of caravan

Market value of caravan (inc. GST)

Year trailer made

Model of trailer

Market value of trailer (inc. GST)

Do you already have a home/contents policy with us? *

Yes

No

How did you hear about our cover?

If you selected other, please provide details

Any other information?

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