Motor Vehicle Insurance Application Form

Motor Vehicle Insurance Application Form
Please answer all questions with a red asterisk, answers such as N/A may delay processing of this application. Questions that are preceded with a † contain definitions of terms or explanations when you hover over them.

If you require insurance for high performance or high value vehicles, or are seeking commerical motor including heavy vehicles or fleet policies, please contact us directly at insurance@delphic.com.au or call us on 1800 DELPHIC.
Personal Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Postcode
Email*
name@example.com
Phone Number*
If a landline, please provide area code

Motor Vehicle Insurance
Is the vehicle either
- unregistered or have any existing damage (including hail damage, but not including minor scratches or wear and tear), or
- used for
  - Driver Education
  - Racing or Sporting Events
  - Courier or Delivery Services
- Or used as a
  - Hire Car
  - Courtesy Car
  - Taxi or
  - Removalist vehicle?
YesNo
We will require you to contact us directly as a standard motor vehicle policy may not be suitable.

Please contact us at insurance@delphic.com.au or call 1800 DELPHIC

Drivers Details
Main Driver
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Year Licence Obtained*
Gender*

MaleFemale
Do you wish to add another driver?*

YesNo
Name*

First NameLast Name
Date of Birth*

DayMonthYear
Year Licence Obtained*
Gender*

MaleFemale
During the last 3 years have you or anyone to be insured under this policy had their licence cancelled, suspended disqualified or restricted?*

YesNo
If Yes please provide more information*

Claims History
During the last 3 years have you had any claims?*

YesNo
Please provide detailed information*
Note the Year of the claim, brief description and claim amount

Motor Vehicle Insurance Application Form

Notice and Acknowledgment
We draw your attention to the Important Notice accompanying this Application form. You must read the Important Notice carefully. If you do not understand the content of Important Notice, please contact us immediately.

If any of the statements in this Application form are untrue, and you have suppressed or mis-stated any facts and/or should any information given by you alter between the date of this Application form and the inception date of the insurance to which this Application form relates you must immediately notify us.

You authorise us to collect or disclose any personal information relating to this insurance to any insurer or insurance reference service. Where you have provided information about another individual (for example, a relative, employee or client), you have or you will make the individual aware of that fact and the section in the Policy on "The way we handle your personal information".

You agree that you have read and understood this notice by doing any of the following:

(a) Signing and returning a copy of this form; or

(b) Providing the information requested and returning the form to us; or

(c) Providing us with instructions to place the policy.
Please sign

Clear
Please attach any supporting documentation here, including your current insurance policy.

Browse Files

Cancelof
Should be Empty:

Motor Vehicle Insurance