Motor Insurance | Insurance Services

First name

Last name

Postal Address

TIN #

Please provide your Tax Identification number here

Phone

Please choose the starting date for this insurance

Month

Day

Year

Time

HoursMinutes

Please select the end date

Month

Day

Year

Trading Name

Complete this field if the vehicle is to be insured under a business name.

Date of birth of proposer

Registration # of Vehicle

Make of Vehicle

Model

Year of Manufacture

Engine #

Chassis #

Seating capacity

Body Type

Purchase Price

Date of purchase

Is the vehicle brand new or used?

If the vehicle is being purchased through a dealership please select below:

What is the market value of the vehicle?

Include the value of accessories in the total. You can provide individual values of the accessories in the next section below.

Please list the accessories included in the total value.

You can list each item and provide the value next to it. If you do not state values, all accessories will be limited to a value of $500.00

Is the vehicle modified in anyway?

If yes, please provide details of these modifications

Is the vehicle is a sound and roadworthy condition?

What is the purpose of use for this vehicle?

Is the vehicle under the ownership and registered under the proposers name?

If not owned by proposer, please state name and address of the owner

Is the vehicle under a hire purchase or lending agreement?

If yes, please states the financier's name

Has the proposer had any motor vehicle related losses in the last two years?

If the proposer has some history to disclose, please also provide details such as:

date of incident,
vehicle #,
the cost of repairs,
brief description of the incident
name of the insurer if applicable.

Has the proposer or any of the drivers of this vehicle been convicted of any driving offence?

If answered yes, we may contact you for more information.

Has the proposer or any of the drivers of this vehicle has or ever had any form of mental or physical infirmity?

If you have answered yes, we may contact you for more information

Has any insurer cancelled, declined to accept, or refused to renew your policy?

We may need more information if you have answered yes.

Is there any other information that is relevant to this insurance application?

Please upload a photo of the vehicle taken from the left

Please upload a photo of the vehicle taken from the right

Please upload a photo of the vehicle taken from the front

Please upload a photo of the vehicle taken from the back

Please upload a photo of the valid ACCF document for this vehicle.

The ACCF is the document issued by the Land Transport Authority on behalf of the Accident and Compensation Commission of Fiji

Please upload a photo of the vehicle registration certificate

You can either upload a photo of the windscreen sticker, or a photo of the vehicle details section of the registration certificate.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

By signing and submitting this form, you are declaring that the above informaiton is true and correct. You also agree that this policy is accepted subject to the terms, exclusions, and conditions of the insurer.

You will also acknowledge that no insurance is in place until this proposal is accepted, and the premium or deposit has been paid in full.

Payments

Please select how payment for this proposal is intended to be completed.