Contact Details

Insured Name

Contact Name

Telephone Number

Email Address

Address

Street Address

Postcode

State

Will there be financing on this equipment?

Yes

Have you had any equipment losses in the last 3 years?

Yes

Do you need Public Liability cover?

Yes

Is the machine registered?

Yes

Year

Manufacturer

Model

VIN/Serial Number

Insured Value (AUD)

Schedule Attachment

Please describe intended machine usage

Other Relevant Information

Machine Insurance is a trading name of Bourchier Nominees Pty Ltd (Licensed insurance brokers) AFS Licence: 238917 ACN: 009 048 677