Motorhome Insurance Enquiry Form

	Please provide us with as much information as possible to assist us in helping you with your enquiry. However only items marked with (*) are required, once we have this information one of our representatives will contact you to assist with your enquiry.
Last Name (*)	Please type your last name.
First Name (*)	Please type your first name.
Address 1	Invalid Input
Address 2	Invalid Input
SUBURB (*)	Invalid Input
STATE (*)	Invalid Input
Postcode (*)	Invalid Input
Contact Telephone (*)	Invalid Input
Alternative Telephone	Invalid Input
Facsimile (if available)	Invalid Input
E-mail (*)	Invalid email address.
How should we contact you?	E-mailPhoneMail
Motorhome Type	Please tell us how big is your company.
Year Built	Invalid Input
Gross Vehicle Mass	Invalid Input
# Years Lic for this vehicle	Invalid Input
Registration Number	Invalid Input
Vin Number	Invalid Input
Serial Number	Invalid Input
Date of Birth	Invalid Input
Name of Financier	Invalid Input
Amount Insured	Invalid Input
Accessories Amount Insured	Invalid Input
List Accessories	Invalid Input
Did you buy your Motor Home new?	Invalid Input
Year of Purchase?	Invalid Input
Purchase Price	Invalid Input
Description of Trailer	Invalid Input
Value of Trailer?	Invalid Input
Annexe Sum Insured	Invalid Input
Contents Limit	Invalid Input
Portable Personal Valuables	Invalid Input
Portable Personal Valuables Description	Invalid Input
No Claims Bonus Years if applicable	Invalid Input
	Questions Section
Has any insurer declined to insure you?	NoYes Invalid Input
Has any insurer declined to renew a policy?	NoYes Invalid Input
Have you ever been charged with insurance fraud?	NoYes Invalid Input
Are you an undischarged bankrupt?	NoYes Invalid Input
Have special conditions ever been set on a policy?	NoYes Invalid Input
Has an increased excess ever been imposed	NoYes Invalid Input
Have you had any prior claims rejected?	NoYes Invalid Input
Details if YES to above	Invalid Input
Tell us of any criminal charges	Invalid Input
Who is your current insurer?	Invalid Input
Policy Number	Invalid Input
Will you be claiming a GST Input Tax credit?	NoYes Invalid Input
If so what % of GST will you claim as ITC?	Invalid Input
How did you find us	Invalid Input
# of Motor vehicle accidents you have had in last 5 years	Invalid Input
# of Motor vehicle fines you have had in last 5 years	Invalid Input
Have you ever had your driver's license or permit…(please tick most appropriate)	CancelledReduced to a lessor gradeSpecial ConditionsSuspended Invalid Input
Accident and Fines Details	Invalid Input
How many motor vehicle claims you have had in last 5 years	Invalid Input
Claim Details	Invalid Input
Name of Insurer	Invalid Input
Will anyone under the age of 25 drive the vehicle?	YesNo Invalid Input
Age of youngest driver	Invalid Input
Privacy Statement	Privacy Statement Manufactured Homes Insurance Agency Pty Ltd (MHIA) and its underwriters and representatives are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Private Sector Act 2000 (the Act)). This sets out basic standards relating to the collection, use, disclosure and handling of personal information. “Personal information” is essentially information or an opinion about a living individual whose identity is apparent or can reasonably be ascertained from the information or opinion. Information will be obtained from individuals directly where possible. Sometimes it may be collected indirectly. Only information necessary for the arrangement and administration of MHIA’s business by MHIA and its underwriters and representatives will be collected. This includes information necessary to accept the risk, to assess a claim and to determine competitive and appropriate premiums. We will only ask for and take into account relevant information. MHIA and its underwriters or representatives disclose personal information to third parties who they believe are necessary to assist them in doing the above. These parties will only use the personal information for the purposes we provided it (or if required by law). When you give MHIA and its underwriters or representatives personal information about other individuals, we rely on you to have made or make them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use it for, and how they can access it. If it is sensitive information we rely on you to have obtained their consent on these matters, before supplying us with the relevant information. You are entitled to access information about you that we have relied on in making decisions that concern your insurance with us. You will also have the opportunity to correct any mistakes or inaccuracies in the information we hold about you. In special circumstances, we may decline to release information but we will not do so unreasonably. Special circumstances may include, but are not limited to, information that is subject to privacy laws, information that is protected from disclosure by law, or where the release of the information may be prejudicial to us in relation to a dispute about your insurance. Where we decline to release information, we will give you reasons and you will have the right to request us to review our decision through our complaints handling procedures. We will provide our reasons in writing upon request. Finally, you may also opt out of receiving materials sent by MHIA by contacting our office on (02) 4303 0300. For the full text of our Privacy Policy, contact our office or refer to our website at http://www.mhia.com.au Invalid Input
(*)	I have read understand and agree with the MHIA privacy statement. You need to acknowledge the MHIA privacy policy to continue

Motorhome Insurance Enquiry Form

Questions Section