Please fill in the details below and we will get back to you shortly. Fields marked with * are compulsory. Personal Details First Name Surname * * Phone Number Male Female * Current City of Residence Address * Date of Birth * Email Address How did you hear about Club Auto Insurance? * Yellow Pages Television Online Other Insurer TOWER Friend Magazine Car Show Radio Have you previously had car insurance? Which insurance cover are you most interested in? Yes No Full comprehensive Third Party Fire/Theft Third Party only If yes, which company and for how long? Drivers Main Driver Name D.O.B. Licence Type Male Female Details of any accidents, driving or criminal convictions for the above from the last 7 years Driver 2 Name D.O.B. Licence Type Male Female Details of any accidents, driving or criminal convictions for the above from the last 7 years Driver 3 Name D.O.B. Licence Type Male Female Details of any accidents, driving or criminal convictions for the above from the last 7 years Driver 4 Name D.O.B. Licence Type Male Female Details of any accidents, driving or criminal convictions for the above from the last 7 years Driver 5 Name D.O.B. Licence Type Male Female Details of any accidents, driving or criminal convictions for the above from the last 7 years Do you or any of the named drivers have any medical conditions which may effect their ability to drive? Vehicle Details Make Model Year CC Rating Turbo/V8/Rotary Market Value Is the vehicle fitted with an alarm and immobiliser NZSA 3 star or better rated? Yes No Make and model What modifications have been made to your car? Additional Information
