Heavy Vehicle Truck Insurance

First Name *

Last Name *

Company / Applicant Name

Telephone *

Email *

Number of Trucks #

Number of Trailers #

Truck Registration *

State of Registration *

Garaging Address

Garaging Address Postcode

Postal Address (If different from above)

Postal Address Postcode

Insurance to quote; (tick box as required)

Comprhensive Machinery or Vehicle Insurance

Carriers Transit / Marine Cargo Insurance

Public / Products Liability Insurance

Mobile Tools Insurance

Other Insurance

assessment and referral <span class='fieldReq'>*</span>

I hereby submit the above details to DA Fleet Management Services Pty Ltd “(DA)’ for sole purpose of assessment and referral. DA will manage the referral process and I consent to DA submitting the above details to an insurer or Insurance Broker and charging a fee for this referral service of $99.00 inclusive of GST. I understand DA is not the insurer and does not guarantee any outcome whatsoever in relation to any insurance quotations or subsequent insurance offers. Please refer my above details to an insurer or Insurance Broker

Heavy Vehicle Truck Insurance

Basic Info

Personal Information

Payment

Payment Information

Credit Card

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