Step 1 of 5 - Personal information 20% Hi, let's get some details for your vehicle quote. Registered Owner Name(Required) First Last Address(Required) Street Address City State Post Code Email(Required) Phone No(Required)Currently insured?(Required) Yes No Expiry date DD slash MM slash YYYY Tell us about Vehicle details.Vehicle Year/Make/Model(Required)Petrol or Diesel(Required)PetrolDieselBody type(Required)Transmission(Required) Rego Number(Required)Purchase PricePurchase Date DD slash MM slash YYYY Engine SizeVIN NumberSecurity Device Fitted?(Required) Yes No if yes, is it an immobiliser, alarm, tracking system, etc?Vehicle Roadworthy & Registered(Required) Yes No If no, please note further details Tell us more details about your vehicle.Use of Vehicle(Required) Occupation(Required)Address where vehicle is left overnight Street Address Parked overnight in(Required) If Other(Required)Finance(Required) Yes No Financier(Required)AccessoriesAccessories valueModificationsModifications valueColour of vehicle(Required)Approx number of kilometres driven per year(Required) Tell us about the drivers claims historyNo Claim Bonus or Rating No(Required)60%/Rating 150%/Rating 240%/Rating 330%/Rating 420%/Rating 50%/Rating 6Subject to written proofDrivers Details(Required)NameDate of Birth (dd/mm/yyy)Years drivingOccupation Please ensure % of Use totals to 100% across all drivers.Have any of the above drivers ever had:Accidents or claims(Required) Yes No Traffic offences (excluding parking)(Required) Yes No Licence cancelled/ endorsed/ suspended(Required) Yes No Criminal convictions(Required) Yes No Bankruptcy(Required) Yes No If yes, to any of the above please give full detailseg date, description, insurer, and value of claimNumber of demerit points lost in the last 5 years*(Required) Additional optionsWindscreen protection(Required) Yes No Hire car after an accident(Required) Yes No Type of Cover Requested(Required) Comprehensive Third Party Fire & Theft Third Party Property Damage Additional notesInformed ConsentWe are required by law to obtain your informed consent to earn commission prior to arranging your policies. Insurer - Australian Approved Type of Insurance Motor Vehicle Insurance Insurance Item - As per application form Range of Commission - 1% to 10% These commissions will be received Monthly or annually, depending on your payment preference for this policy. The services that we will provide are outlined in our terms of engagement document. This consent will apply to future renewals of these policies and is irrevocable. The parties may vary the consent by agreement. We will contact you to request a modification of your consent regarding the renewal or alteration of an insurance product if any of the following situations change: the product issuer changes; there is an additional monetary benefit as a result of the variation/endorsement (that is a benefit in addition to the commission payable at the rate and frequency as set out in the existing informed consent); the rate of the monetary benefit increases; or the frequency of any monetary benefit changes. I have read and understood that City Rural Insurance Brokers Pty Ltd earns commission as outlined in the above correspondence and confirm my consent to them receiving commission(Required) I AcceptThanks for your details, please confirm you are not a robot and we'll get onto your quote request straight away. We'll make contacts directly to you via email. CAPTCHALinkedInThis field is for validation purposes and should be left unchanged.
