TGN Vehicle Insurance Quote Form

Date you wish to Start cover

Date

Renewal Date for current policy

Date

Make

Customer Name

First NameLast Name

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Type of Use

What type of business is the vehicle used for?

Model

Registration

Does the vehicle have an alarm and/or immobiliser?

Is the vehicle parked in a locked garage at night?

Does the vehicle have any existing damage or defects?

Please provide details of existing damage

Does the vehicle have accessories with a total value of over $1,000 or has it been modified?

Please select those that apply:

Is the vehicle petrol turbocharged or supercharged?

Is the vehicle on finance or lease?

Name of Finance Company

Driver Details -

NOTES for Driver Details above

Licence - Number of years a driver has held a drivers licence

Accidents - Please select the number of at fault or theft losses the driver has had in the last 2 years

Main - Please indicate which driver will be driving this vehicle most of the time. If the vehicle is to driven equally by more than one driver select the youngest.

Named - Naming a driver entitles you to a discount on your premium. You can name a maximum of 2 drivers and they can both be over 25 years of age. Naming drivers does not preclude other people from driving this vehilce but a higher excess (refer to the policy wording) will apply should they be involved in an accident in this vehicle.

Driver Declaration Questionnaire

	Yes	No
Do any of the drivers have any mental or physical condition or impairment that could affect driving ability? - Excludes wearing glasses and/ or contact lenses *
Have any of the drivers had any special conditions imposed on a motor policy? Includes imposed excesses, exclusions and premium loadings *
Have any of the drivers had a driving licence suspended, cancelled or special conditions imposed? Excludes licence conditions when driver must wear glasses when driving *
Have any of the drivers accumulated 51 or more demerit points on their driving licence record in the last 5 years? If in the last 5 years you have incurred 51 demerit points or more in any 2 year period, you must provide us with details of each driving offence. Note - NZTA issues a letter to every driver that accumulates this many points. *

Driver Options

Driver Option Information

Open Driver Policy

Provides cover for any licenced driver using the vehicle, with no restriction on the amount or age of those drivers.

Exclude all under 25yr Drivers

Provides cover for any licensed driver over the age of 25 years old using the vehicle. There will be no cover at all if a driver under 25 years old is in control of the vehicle at the time of an accident of loss. Only available with comprehensive cover.

Voluntary Named Drivers

If the vehicle is unlikely to be driven by licensed drivers other than the selected main driver and one other named driver, select this option. If any driver other than the named driver(s) is in control of the vehicle at the time of an accident or loss, an additional excess will apply. Only available with Comprehensive cover.

Voluntary Named Drivers & Exclude all under 25s

If the vehicle is unlikely to driven by licensed drivers other than the selected main driver and one other named driver and no drivers under 25 years old will drive the vehicle, select this option. There will be no cover at all if a driver under 25 years old is in control of the vehicle at the time of an accident or loss and where any driver over the age of 25 years old, other than the named driver(s), is in control of the vehicle at the time of an accident of loss, an additional excess will apply. Only available with Comprehensive cover.

What Excess do you wish to select

Premium Instalment Frequency

A service fee is charged for premiums paid by instalments other than annually.

Duty of Disclosure
Subject to any rights you have under the Criminal Records (Clean
Slate) Act 2004, the information given is in every respect correct and
complete and all material information has been disclosed to Vero,
whether the information is asked for or not. Material information
is information that might influence our decision to insure you and
if so on what terms and / or premium. If you have any doubt as
to whether a fact is material then it must be disclosed. The duty to
disclose all material information occurs prior to the commencement
of cover, if the contract is varied and prior to each renewal. Failure
to disclose all material information may result in Vero avoiding your
insurance policy. This means your policy would be deemed never to
have existed and any claims would not be payable.

The information contained in this document shall be the basis of the
contract between you and Vero, and you are willing to accept cover
subject to Vero’s policy terms, conditions, exclusions and any special
terms that Vero may require.

Insurer Financial Strength Rating
Vero Insurance New Zealand Limited has been given an A+ Insurer
Financial Strength. Rating by Standard and Poor’s. The rating scale is:
Ratings from ‘AA’ to ‘CCC’ may be modified by the addition of
a plus (+) or minus (-) sign to show relative standing within the
major rating categories.

The rating scale above is in summary form. The full version of this
rating scale can be obtained from www.vero.co.nz

AAA Extremely Strong
AA Very Strong
A Strong
BBB Good
BB Marginal
B Weak
CCC Very Weak
CC Extremely Weak
SD Selective Default
D Default
R Regulatory Supervision
NR Not Rated

Privacy Act 1993
Vero has collected your personal information in order to evaluate
your insurance requirements for the purpose of deciding whether
to issue insurance cover and, if so, on what terms. Failure to provide
any personal information requested by Vero may result in your
application for insurance being declined.

Vero has also collected your personal information in order to
monitor and service your ongoing general insurance requirements,
conduct market research, data processing and statistical analysis.
Unless you notify Vero that you disagree, the information you supply
may also be used by Vero to provide you with information about
other facilities, products and services.

Your personal information is held by Vero. In accordance with
the Privacy Act 1993, individuals have a right to request access
to and correction of their personal information (a fee may be
payable) by contacting Vero, 48 Shortland Street, Auckland 1010.

Authorisation
You authorise Vero to give to and obtain from other Insurance
Companies, Insurance Brokers, the Insurance Claims Register
Ltd or any other party, any information relating to this or any
other insurance held or previously held by you, and any claim(s)
made by you, and any information you have provided now or
previously for the purpose of payment.

You also authorise Vero to disclose personal information about you
to it’s related companies (as defined by the Companies Act 1993), all
it’s present and future contracted insurance product manufacturers
and / or authorised representatives for these purposes.

Signature of Applicant (s)

Date

TGN Vehicle Insurance Application