If you would like a quote for your Motor Vehicle policy, please complete the below form.  Once submitted one of our brokers will prepare a quotation and be in contact with you.

 

Privacy

We are committed to protecting your privacy. We use the information you provide to advise about and assist with your insurance and/or financial planning needs. We only provide your information to insurance companies, underwriting agencies, wholesale brokers and premium funders with whom you choose to deal (and their representatives). We do not trade, rent or sell your information. If you don't provide us with full information, we can't properly advise you and you could breach your duty of disclosure. You can check the information we hold about you at any time.

For more information about our Privacy Policy, ask us for a copy or view here. By completing the request below, I certify that I am aware that any collection of personal information is used in accordance with EBM's Privacy Policy.
Contact Person*:
Contact Phone*:
Contact Email*:
Contact Postal Address*:
Name of Registered Owner*:
Driver Details:
Registered Driver*:
Date of Birth*:
% of Use*:
Years Driving*:
At fault claims last 3 years*:
Gender*:
Other Regular Driver:
Date of Birth:
% of Use:
Years Driving*:
At fault claims last 3 years*:
Gender*:
Vehicle Details:
Year*:
Registration No.*:
Make & Model*: (eg: Kia Pregio)
Body Type*: (eg: Sedan or Ute)
Colour*:
Modifications*:
Series:
Transmission*:
Use of Vehicle*:
Business Description: (eg: courier, carpenter)
Security*: (eg: Alarm, Immobiliser)

Was the car purchased as new                        

in the last 12 months?*:

 

If Yes; Year, Value & Purchased from:                 

 

If No, What year was the vehicle purchased?   

 

Suburb where parked at night*:
Type of parking*:
Type of Cover:
Basis of Settlement:?
Sum Insured:
No Claim Bonus %:
Accessories
Cover Required:
Finance:
Interested Party*:
Finance Type*:
Optional Benefits:
NCB Protection*: (one at fault claim per year without reduction in NCB)
 
Hire car following an accident*:
Windscreen Protection*: (one windscreen/window claim per year without the application of excess or loss of NCB)


 
Tools of Trade*:
Voluntary Excess:
Is a voluntary excess for reduction in premium to be included in the quote:
 
If yes, how much?
Loss History - has the registered owner/insured &/or any driver to be nominated in the policy:
 
1. Has any insurer refused or cancelled cover on any of your policies or required special terms to insure you in the past 12 months?*


 
2) Have you, or any person who will drive your car(s), in the past 12 months
 
a) Been charged with, or convicted of, or penalised for, any motoring offences? (This includes on the spot fines but does not include parking offences)*




 
b) Had a driving licence suspended, cancelled or restricted by endorsement?*


 
c) Been charged or convicted of any criminal offence?*


 
3) Has your car been modified or converted from the Maker's specifications or fitted with accessories other than those supplied as Maker's options?*




 
4) Are there any other material facts that you need to tell us? (refer to your policy booklet)*


 
If yes to any questions, please give details (including dates and amounts paid or penalty received)
Additional Comments
Preferred Method Of Contact*
 

Key Contacts

Specialists in this area include:

 

gareth greaves

VIC, NSW, SA & TAS

 

Gareth Greaves

Commercial Division Manager - Melbourne

email Gareth

jonnine gould

Perth & NT

 

Jonnine Gould

PersonalCover Division Manager

email Jonnine

 

Chritopher Traill

QLD

 

Christopher Traill

Executive Account Manager

email Chris

Bunbury

 

Kushla Harris

Assistant Account Manager

email Kushla

 

Kalgoorlie

 

Rachael Anderton

PersonalCover Account Manager

email Rachael

Geraldton

 

Natasha Pirrottina

Account Manager

email Natasha

Karratha

 

Suzanne Kimpton

Assistant Account Manager

email Suzanne

 


Quick Contact Form

EBM are able to provide a wide range of services, many of these will require a professional to contact you to discuss precise requirements.

For a general enquiry, complete the below. For a more detailed enquiry please click here.

Privacy Acknowledgement - For more information about our Privacy Policy, ask us for a copy or view here. By completing the request below, I certify that I am aware that any collection of personal information is used in accordance with EBM's Privacy Policy.*
Agreed


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