Cabsafe - Regional Taxi Insurance

Cabsafe Quote Request

The Insured

Surname or Company Name:

First Name(s):

Postal Address:

Suburb:

State / Post Code:

Telephone

Mobile

Date of Birth (if applicable)

The Vehicle

Year of Manufacture

Make

Model

Type of body

Registration Number

Engine Number

Vehicle Identification Number

Date of Purchase

$ Purchase Price

List and value of cab accessories if more than $3,000 in value

Finance Company Name (if any)

Underwriting Information

Which Town does your taxi operate from?

Is your vehicle used for any purpose other than a taxi?

Yes No

(If Yes provide details of use)

Will the vehicle be used to carry Dangerous Goods?

Yes No

Have you ever been convicted of a criminal offence or been declared bankrupt?

Yes No

Have you had any insurance declined or special terms imposed in the last 5 years?

Yes No

Has the vehicle been modified from the manufacturer's specifications so that its performance is altered?

Yes No

If any of the questions above have been answered yes then full details should be provided below.

Insurance History

Give the following details of motor insurance held by you during the past three years.

Policy Period	Insurer	Policy Number	Type of Insurance (Taxi Insurance or other Motor Insurance)

To qualify for a No Claim Bonus Entitlement on your Cabsafe Insurance we will require a current renewal notice or letter from your previous insurer.

Driving History

Give the following details of motor vehicle accidents or driving offences during the past five years that you or any intended driver may have had. (If space is insufficient please detail seperately and email to our office.)

Date of claim or offence	Amount of claim or the fine for the offence	Details of the claim or the offence

Separate Driver Declarations will be required if we need further information about driving history.

Declaration

I/We declare that the answers given herein are in every respect true and correct.
I/We have not withheld any information likely to affect the acceptance of this proposal.
I/We have had the opportunity to read and understand the Financial Services Guide and Product Disclosure Statement.

I Agree

Cabsafe Regional Taxi Insurance is a specialist division of Allsafe Insurance Brokers Pty Ltd
ABN 44 010 468 818 AFS Licence No. 239041

Please forward additional material if required to info@allsafe.com.au clearly identifying the sender.