Welcome to Max Insurances
Phone 0508 629 5626
D1, 27-29 William Pickering Drive, Rosedale, 0632
Tel: 09 913 3011 Fax: 09 913 3012
Your Name
Date of Birth
Your Address
Contact Number
Your Email
Do you have existing car insurance YesNo
If you have, could you tell us the insurance company name and your customer & policy no.
Vehicle Use PrivateBusiness
If your vehicle is used for business purposes, could you tell us the business type
Year
Make
Model
CC Rating
Registration No.
Value $
Alarm and/or Immobiliser YesNo
Parked in Locked Garage YesNo
Any Existing Damage or Defects YesNo
If your answer is 'yes' to previous question, please describe
Does your vehicle have non-factory fitted accessories valued over $1000 or modified in any way YesNo
If your answer is 'yes' to previous question, please detail
Is the vehicle on finance or lease YesNo
If your answer is 'yes' to previous question, what's the company
Who will be the main driver
What driving licence do you hold and how long have you held your licence for
Have you had any motor claims in the past 12 months YesNo
Any other relevant information that may affect the insurance cover
Declaration: I/WE HEREBY DECLARE AND WARRANT that the answers given above are in every respect true and correct, and that I/We have not withheld any information within My/Our knowledge likely to affect the decision of the Company as to My/Our eligibility for insurance. This request and declaration shall be the basis of the quote request. YesNo
All Finance Funds Ltd FSP 564207 - T/A Max Insurances NZBN (9429046167460) Providing Financial Products (General Insurance) as an agent of Insure247 Limited (FSP626729) NZBN (9429046774224). A disclosure statement is available, on request and free of charge.
