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Sunshine Coast 1800 072 114 | Central Queensland 1800 961 007 | North Queensland 1800 629 701

Steel Pacific Insurance Brokers

The Steel family established Pacific Insurance Brokers in 1982, opening offices in both the Solomon Islands and Vanuatu.

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Non HMIS Motor

Non HMIS Motor - Questionaire

Client Code:*
Name of person completing questionnaire:*
Insured Name:*
Motor, Plant & Machinery Insurance
1) If you Hire-In Plant or Vehicles (including trailers), please advise the estimated maximum duration of each hire and also the highest valued item.*
2) If not already provided in your Policy are you interested in excess free windscreen cover for an additional premium?*
- Yes
- No
3) If available, are you interested in covering the hire costs for a similar vehicle following an accident?*
- Yes
- No
4) Please provide a description of your current business activities.*
Driver Disclosures
5) Please provide details of any person under 25years of age or with less than two (2) years driving experience, that may drive or operate any of the insured units:*
6) Details of any Motor Insurance and/or claims refused and/or cancelled and/or imposed special terms in the last five (5) years:*
7) To the best of your knowledge, details of any convictions for driving under the influence of alcohol or drugs (DUI) and/or exceeding the prescribed content of alcohol (PCA) in the last three (3) years:*
8) To the best of your knowledge, have any employed drivers had a licence suspended or cancelled in the last five (5) years?*
- Yes
- No
If 'Yes', please provide details
9) To the best of your knowledge, have any employed drivers been convicted of a total of more than two (2) traffic offences (excluding parking) in the last three (3) years?*
- Yes
- No
If 'Yes', please provide details:
Claims
10) Details of any claims that have occurred, but have not yet been reported.*
11) After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to claims in the future.*
All changes or inclusions of any sort or type, including limits or sums insured shown, will take effect from the policy's expiry date unless you request otherwise.
Information we have provided is to the best of our knowledge correct.
Office Message Recipient
Select the office you want to which you wish to send your message*
- Maroochydore
- Townsville
- Proserpine
- Mackay
- Ingham
Information we have provided to Steel Pacific Insurance Brokers, is to the best of our knowledge correct. Please type your name below:*
Comments
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Steel Pacific Insurance Brokers

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1800 072 114

Central Queensland
1800 961 007

North Queensland
1800 629 701

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Ballyglisheen Pty Ltd trading as Steel Pacific Insurance Brokers
ABN 47 075 780 353
AFSL 230634

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