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Obtain a Motor Insurance Quote

Date
Date Format: DD slash MM slash YYYY
Commence From
Date Format: MM slash DD slash YYYY
Client Name
D.O.B
Date Format: DD slash MM slash YYYY
Client Name 2
D.O.B
Date Format: DD slash MM slash YYYY
Address
Street Address Address Line 2 City State Post Code
Phone
Email*
Drivers Licence
Type
- Third Party
- Comprehensive
- Fire & Theft
Vehicle Usage
- Private
- Business
Make
Year
Model
Transmission Type
- Auto
- Manual
Agreed Value
Registration
Vehicle Type
- Sedan
- Ute
- Van
- 3 Door Hatch
- 5 Door Hatch
Cylinders
- 4
- 6
- 8
- Turbo
Engine
- Petrol
- Diesel
Optional Features
- Metallic Paint
- Sunroof
- Leather
- Other
Parking
- Garage
- Carport
- Driveway
- Street
Security
- None
- Alarm
- Immobilizer
- Kill Switch
Claims History
Finance
- Yes
- No
Finance Company
Hire Car
- Yes
- No
Windscreen
- Yes
- No
Listed Driver
- Yes
- No
60% No claims bonus
- Yes
- No
Current Insurer
Amount
Related Documents
Drop files here or
If you would like to send the Resilium Claims team any documentation or photos in support of your claim, you may do so by selecting a maximum of 2 files that will be sent with the information above.
Current Policy Expiry Date
Date Format: DD slash MM slash YYYY
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Comments
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Contact

PO Box 333 WELLAND SA 5007

08 8244 9999
08 8244 9955
(For local callers)

1300 660 191
1300 660 192
(Interstate local call cost only)

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Securitex Financial Services Pty Ltd, Authorised Representative of:
Resilium Pty Ltd, ABN 40 098 080 810, AFSL 232703 and
Resilium Insurance Broking Pty Ltd ABN 92 169 975 973, AFSL 460382

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