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Private Motor

Available for most types of vehicles which are used for Private use and also business use, excluding Couriers. Please list all modifications and accessories to ensure we are able to correctly quote on your vehicle. Cover options available are Comprehensive, Third Party Fire and Theft, Third Party Property Damage.

In order for City Rural Insurance Brokers to provide you with an Obligation Free Quote, please complete the following.

Fields designated in RED are required to be completed

PERSONAL INFORMATION
Registered owner
Street address
 Suburb/Town
State
 Postcode
Email Address
 Phone
Fax
 Mobile Phone
Preferred method of contact
Email   Phone   Fax 		 
How Many Cars?   
VEHICLE DETAIL 1
Year
 Make
 Model 
Body Type 
 Transmission Type
Auto Touchtronic   Automatic   Manual   Tiptronic
Purchase Price
 Engine Size
 Rego Number
Is the Vehicle fitted with an Alarm/Immobiliser?   Yes   No
Vehicle Roadworthy & Registered:   Yes   No
If No, further details please
Modifications: 
Accessories: 
Vehicle use:   Private?       Business?    Occupation
Suburb where vehicle is kept overnight    
Garage   Driveway   Carport   Street
Postcode     Financed?:   Yes   No
INSURANCE HISTORY OF CAR 1
Current No Claim Bonus or Rating (Subject to Written Proof) If not known, Number of Years Insured without a Claim?
0%/0yr    20%/1yr    30%/2yr    40%/3yr    50%/4yr    60%/5yr
Current Insurer 
Expiry date 
Cover Type?
Comprehensive
Agreed Value (Value)
Third Party Fire & Theft (Value)
Third Party Property Damage  
VEHICLE DETAIL 2
Year
 Make
 Model 
Body Type 
 Transmission Type
Auto Touchtronic   Automatic   Manual   Tiptronic
Purchase Price
 Engine Size
 Rego Number
Is the Vehicle fitted with an Alarm/Immobiliser?   Yes   No
Vehicle Roadworthy & Registered:   Yes   No
If No, further details please
Modifications: 
Accessories: 
Vehicle use:   Private?       Business?    Occupation
Suburb where vehicle is kept overnight    
Garage   Driveway   Carport   Street
Postcode    Financed?:   Yes   No
INSURANCE HISTORY OF CAR 2
Current No Claim Bonus or Rating (Subject to Written Proof) If not known, Number of Years Insured without a Claim?
0%/0yr    20%/1yr    30%/2yr    40%/3yr    50%/4yr    60%/5yr
Current Insurer 
Expiry date 
Cover Type?
Comprehensive
Agreed Value (Value)
Third Party Fire & Theft (Value)
Third Party Property Damage  
VEHICLE DETAIL 3
Year
 Make
 Model 
Body Type 
Transmission Type
Auto Touchtronic   Automatic   Manual   Tiptronic
Purchase Price
 Engine Size
 Rego Number
Is the Vehicle fitted with an Alarm/Immobiliser?   Yes   No
Vehicle Roadworthy & Registered:   Yes   No
If No, further details please
Modifications: 
Accessories: 
Vehicle use:   Private?       Business?    Occupation
Suburb where vehicle is kept overnight    
Garage   Driveway   Carport   Street
Postcode    Financed?:   Yes   No
INSURANCE HISTORY OF CAR 3
Current No Claim Bonus or Rating (Subject to Written Proof) If not known, Number of Years Insured without a Claim?
0%/0yr    20%/1yr    30%/2yr    40%/3yr    50%/4yr    60%/5yr
Current Insurer 
Expiry date 
Cover Type?
Comprehensive
Agreed Value (Value)
Third Party Fire & Theft (Value)
Third Party Property Damage  
VEHICLE DETAIL 4
Year
 Make
 Model 
Body Type 
 Transmission Type
Auto Touchtronic   Automatic   Manual   Tiptronic
Purchase Price
 Engine Size
 Rego Number
Is the Vehicle fitted with an Alarm/Immobiliser?   Yes   No
Vehicle Roadworthy & Registered:   Yes   No
If No, further details please
Modifications: 
Accessories: 
Vehicle use:   Private?       Business?    Occupation
Suburb where vehicle is kept overnight    
Garage   Driveway   Carport   Street
Postcode    Financed?:   Yes   No
INSURANCE HISTORY OF CAR 4
Current No Claim Bonus or Rating (Subject to Written Proof) If not known, Number of Years Insured without a Claim?
0%/0yr    20%/1yr    30%/2yr    40%/3yr    50%/4yr    60%/5yr
Current Insurer 
Expiry date 
Cover Type?
Comprehensive
Agreed Value (Value)
Third Party Fire & Theft (Value)
Third Party Property Damage  
VEHICLE DETAIL 5
Year
 Make
 Model 
Body Type 
 Transmission Type
Auto Touchtronic   Automatic   Manual   Tiptronic
Purchase Price
 Engine Size
 Rego Number
Is the Vehicle fitted with an Alarm/Immobiliser?   Yes   No
Vehicle Roadworthy & Registered:   Yes   No
If No, further details please
Modifications: 
Accessories: 
Vehicle use:   Private?       Business?    Occupation
Suburb where vehicle is kept overnight    
Garage   Driveway   Carport   Street
Postcode    Financed?:   Yes   No
INSURANCE HISTORY OF CAR 5
Current No Claim Bonus or Rating (Subject to Written Proof) If not known, Number of Years Insured without a Claim?
0%/0yr    20%/1yr    30%/2yr    40%/3yr    50%/4yr    60%/5yr
Current Insurer 
Expiry date 
Cover Type?
Comprehensive
Agreed Value (Value)
Third Party Fire & Theft (Value)
Third Party Property Damage  
INSURANCE DECLARATIONS
Have your ever had: DRIVER 1 DRIVER 2
Accidents or Claims Yes
No		 Yes
No
If yes, please supply details - Driver 1
If yes, please supply details - Driver 2
Traffic Offences (excluding parking) Yes
No		 Yes
No
If yes, please supply details - Driver 1
If yes, please supply details - Driver 2
Licence Cancelled / Endorsed / Suspended Yes
No		 Yes
No
If yes, please supply details - Driver 1
If yes, please supply details - Driver 2
Insurance Refused / Declined / Cancelled Yes
No		 Yes
No
If yes, please supply details - Driver 1
If yes, please supply details - Driver 2
Criminal Convictions Yes
No		 Yes
No
If yes, please supply details - Driver 1
If yes, please supply details - Driver 2
OPTIONS
Windscreen Protection:      Yes    No
DRIVERS
Please supply details of all drivers
DRIVER 1
Name DOB
Occupation Years Exp.
Vehicle Driven % of Use
DRIVER 2
Name DOB.
Occupation Years Exp.
Vehicle Driven % of Use
DRIVER 3
Name DOB.
Occupation Years Exp.
Vehicle Driven % of Use
DRIVER 4
Name DOB.
Occupation Years Exp.
Vehicle Driven % of Use
I have read the Duty of Disclosure (view)
Duty of Disclosure

In order to make an informed assessment of the risk and calculate the appropriate premium, your insurer needs information about the risk you are asking it to insure.

For this reason, before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 to disclose to your insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk and, if so, on what terms. The duty also applies when you renew, extend, vary or reinstate a contract of insurance.

You do not have to disclose anything that:

  • Reduces the risk to be undertaken by the insurer;
  • Is common knowledge;
  • Your insurer knows, or in the ordinary course of its business, ought to know; or
  • If the insurer has waived your obligation to disclose.
If you do not comply with your duty of disclosure, your insurer may be entitled to reduce its liability in respect of a claim or may cancel your contract of insurance. If the non-disclosure was fraudulent, the insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that you were never insured.

One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As you are responsible for checking that you have made complete disclosure, we suggest that you keep an up to date record of all such losses and claims.
Signature
Title 		Dated

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Australian Financial Services Licence No 237491 – General Insurance Broker

 

 

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Australian Financial Services Licence No 237491

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