Contact us

Fill out the form provided and we will send you information regarding the type of insurance cover you require. Fields marked with an asterisk (*) must be completed.

Personal Details

Full name: * Email: * Phone: * Fax: Postal address:

Types of insurance covers

House Contents Motor vehicle Classic cars Boat Travel Life Superannuation Income Health Business

House Details Year built: No of units: Area of home: sq m Excess $: Construction: Brick Not brick Occupancy: Owner occupied Rental Holiday home Connected to water mains supply: Yes No Number of continuously insured, claim free years: Claim within the last 12 months?: Yes No If yes, please state details: Replacement value if tenanted/holiday home?:

Content Details Value of content $: Excess $: Professionally installed burglar alarm: Yes No Is the alarm monitored?: Yes No Number of continuously insured, claim free years: Claim within the last 12 months?: Yes No If yes, please state details:

Motor Vehicle Details Year, Make & Model: Sum insured for: $: Age of main driver: (the age of the driver who most often uses the vehicle) Engine size: License details : Previous insurance (How many years?): Type of cover required? (Full/TPFO/TPO): Any accidents, claims, convictions, loss of license etc?: Named Driver Discount: Yes No (cover will be limited to the Main Driver) Premier Driver Discount: Yes No (have you held a vehicle policy for at least 5 years) Yes No (have you claimed on that policy during the last 5 years)

Prestige/Classic Vehicle Details Year, Make & Model: Sum insured for: $ Age of main driver: (the age of the driver who most often uses the vehicle) Policy Conditions There is no cover while the vehicle is being driven by or under the control of any person under the age of 25 The annual mileage is not to exceed 3,000 miles (5,000 kms) The vehicle is only to be used for private, social or domestic purposes and as a secondary means of transport The vehicle is to be suitably garaged and secured whilst not in use. The garage or storage facility must be capable of being adequately secured. The insured must have current and continual membership of a recognised Veteran, Vintage or Classic Car Club or similar enthusiasts club. Do you fit the above criteria? Yes No If No, please provide full details:

Marine Pleasure Craft Details Year built: Make: Name: Value (include motors & trailer): Construction: Designed speed of the vessel in knots: (17 knots = 19.5mph) Length: Primary Power: Inboard motor Outboard motor Sail N/A

Travel Details Where are you going? Which dates will you be leaving and returning? (leaving) (returning) $75 or nil excess?

Comments:

I consent to receive email from Roughton Nelson at the email address provided in this form. Please be assured we will only use the information you provide for our own use, as stated in our privacy statement.

Address: 310 Tristram Street PO Box 457 Hamilton
Tel: 07 839 0110
Fax: 07 839 0401
Free: 0800 650 911