Insurance Form VEHICLE INFORMATION Vehicle Details: Year / Make / Model Vehicle Registration If applicable Insured Amount $ INSURED'S DETAILS Insured's First and Middle Name/s Your First and Middle Name/s as on your Driver's License Insured's Surname Your Surname as on your Driver's License Other Names Used Family Name, Also Known As Date of Birth * MM DD YYYY Gender * Male Female Other Prefer not to say Mobile * Email * Driver's Licence / ID type * Please use a Driver's Licence unless you do not have one Full Restricted Learner International Passport Other Driver's Licence / ID Number * Driver's Licence Version Number * Driver's Licence / ID Expiry Date * MM DD YYYY ADDRESS INFORMATION Tenancy type * Own home Renting Boarding Supplied by Employer Living with Relatives Current Address * Address 1 Address 2 City State/Province Zip/Postal Code Country INSURANCE RISK QUESTIONS In The Past 5 Years, Have you Had Any Payment Defaults * Yes No If you selected 'Yes', which Companie/s did you defaulted to? Would You Prefer Payments * Weekly Fortnightly Monthly Payment Amount You Are Comfortable With $ Preferred Date Of First Payment MM DD YYYY I authorize Good Lending (and any associated Finance Companies ) to contact any Credit Reporting Agencies, Credit Providers, my Employer, Ministry of Justice or any other source to obtain, check and exchange such personal, financial and commercial information and references about me as is necessary for the purposes of considering this application. I agree that Good Lending (and any associated Finance Companies ) may in the future provide information to associated parties for the purposes of collecting information for the protection and administration of any loan arising out of this application, and to assist in the enforcement of any agreement between Good Lending and/or any finance company. Under the provisions of the Privacy Act 1993, you are entitled to have access to and request correction of personal information held about you. * I agree I disagree If you have ticked I disagree, please explain in more detail. Todays date * MM DD YYYY Checkbox Option 1 Option 2 3 3 Thank you!
