Private Motor Vehicle Insurance Application Form

Private Motor Vehicle Insurance Application Form
Thank you for requesting a quotation for your Private Motor Insurance. This application form will allow us to collect the necessary information to seek quotations on your behalf, and in some cases, there may be a requirement to provide additional information.

When completing this application form, it is important that you review the policy options, and also note the optional extras on the vehicle, and any added accessories and/or modifications. You need to then review your sums insured to ensure that they are adequate and potentially reflect the movement in higher costs of replacement or repair.  In the event of a major loss, being under-insured can have substantial financial impacts on you.

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 Commerical Motor including heavy vehicles or fleet policies, please contact us directly at insurance@delphic.com.au or call us on 1800 DELPHIC.

Private Motor Vehicle Insurance Application Form

INFORMED CONSENT

Consistent with our commitment to transparency and as required by law, we are seeking your informed prior consent to receive commission in relation to the general insurance products we will recommend to you.

The commission we will receive from the insurer(s) is included in the premium paid by you. It is part of our remuneration for the advice and ongoing support we provide in relation to your insurance needs, as set out in our Terms of Engagement. For your understanding, the details of the Commission are as follows:

Insurer	Annualised % of Base Premium	Frequency Paid
Insurer determined by outcome of marketing process	0 to 15%	Annually

If it’s in your interest, we may recommend that renewal of your policy is placed with an alternative insurer (you can find the list of alternative insurers with whom we may place your policy by visiting Insurer Partners or by asking us for a copy). Each of these insurers pay a rate within the band provided above. The name of the selected insurer and the exact dollar figure of the amount of commission we receive will be disclosed in our quotation document and/or tax invoice.

Your Consent

We ask for your consent to be paid by the relevant product provider the commission set out above. Your consent is irrevocable and will apply to all new policies and future renewals, endorsements and variations of general insurance retail policies placed by us unless there is a material change in the rate of commission.

Is consent provided?

YesNo
Please be advised that by not providing consent, we will not proceed to seek quotations on your behalf.

If you require further information prior to providing consent, please contact us directly to discuss your queries by calling us on 1800 DELPHIC (1800 335744), or if you prefer to schedule a mutually suitable time, you can do so by clicking HERE

You are welcome to continue completing this application form pending our discussion, however be advised that we will not action any requests until an agreement has been made.

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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

Duty of Disclosure
Have you been declined insurance in the past 12 months*

YesNo
Please provide more information*
Have you been charged with a criminal conviction in the last 5 years?*

YesNo
Please provide more information*
Have you declared bankrupt in the last 5 years?*

YesNo
Please provide more information*

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

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Private Motor Vehicle Insurance Application Form

Private Motor Vehicle Insurance Application Form

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Personal Information

Motor Vehicle Insurance

Vehicle Details

Cover Details

Drivers Details

Claims History

Duty of Disclosure

Motor Vehicle Insurance Application Form