Motor Vehicle Insurance claim

Insured

Name of Insured(Required)

Postal Address(Required)

Postcode(Required)

Phone Number(Required)

Email address(Required)

Occupation

What is your Australia Business Number (ABN)?

Are you Registered for GST?

Yes

To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?

Are you the sole owner of the insured vehicle?(Required)

Yes

If NO, who is the owner?

Insured Vehicle

Make, Model & Year(Required)

Year(Required)

Rego Number(Required)

Rego Exp date(Required)

Colour(Required)

Engine Number(Required)

Chassis No(Required)

Class of Vehicle(Required)

Driver

For parked or unattended vehicles, Driver = Vehicle custodian at the time of loss.

Surname(Required)

Given Name(s)(Required)

Address(Required)

Phone No.(Required)

Date of Birth(Required)

Gender(Required)

Female

Male

Drivers Licence(Required)

Expiry Date(Required)

Years held(Required)

Registered owner of vehicle(Required)

Are you an employee(Required)

Yes

If no, state relationship

Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years?(Required)

Yes

If “Yes”, please give details?

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years.(Required)

Yes

If yes, please provide details

Did you consume alcohol or take any drugs during the 12 hours prior to the accident?(Required)

Yes

If “Yes”, please state how much and when

Did you undergo a breath test or blood test for alcohol or drugs?(Required)

Yes

If Yes what was the result.

Did you refuse to undergo any of the above tests?

Yes

Damage to insured vehicles

Was your vehicle damaged?(Required)

Yes

Was your vehicle towed away?(Required)

Yes

Have you obtained a repair quote?(Required)

Yes

If not drivable where can the vehicle be inspected?

Full Address(Required)

Phone No(Required)

Accident Details

Date(Required)

Time am/pm(Required)

Vehicle Use(Required)

Business

Private

What was the accident location?

Street(Required)

Suburb(Required)

P/code(Required)

How did the accident happen?(Required)

Who do you consider was at fault?(Required)

Myself

Other Driver

Other

Estimate speed of YOUR vehicle just before the accident(Required)

KPH

Estimate speed of OTHER vehicle just before the accident(Required)

KPH

What was the condition of the road?(Required)

How was the visibility?(Required)

Good

Moderate

Poor

Were there any witnesses to the accident?(Required)

Yes

If Yes please provide names and addresses(Required)

Name

Address

Did the police attend the accident?(Required)

Yes

If Yes, Police station(Required)

Name/Number of officer(Required)

If No, state time and date reported to police(Required)

Did Police indicate who was responsible(Required)

Yes

If Yes, Name driver(Required)

Did Police charge either driver or suggest action may be taken?(Required)

Yes

Charge

Damage to other vehicle or property

Vehicle or Property No 1

Name of other driver

Age

Phone No.

License No.

Vehicle Make & Model

Rego No.

Name of Registered Owner

Address

Phone No.

The other Insurance Company

Policy Number

Rego No.

Description of Damage

Vehicle or Property No 2

Name of other driver

Age

Phone No.

License No.

Vehicle Make & Model

Rego No.

Name of Registered Owner

Address

Phone No.

The other Insurance Company

Policy Number

Description of Damage

Personal Injuries

Was anyone injured in the accident?(Required)

Yes

Injured persons(Required)

Name

Type of Injury

Injured Party (Passenger/Driver)

Vehicle (Registration No.)

Privacy

The Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.

Internal Dispute Resolution (IDR) Statement

Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).

Declaration

1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.

Please type your name below to agree to our terms(Required)

Date(Required)

Attachments

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Business Insurance

Personal Insurance

Insured

Insured Vehicle

Driver

Damage to insured vehicles

If not drivable where can the vehicle be inspected?

Accident Details

What was the accident location?

Damage to other vehicle or property

Vehicle or Property No 1

Vehicle or Property No 2

Personal Injuries

Privacy

Internal Dispute Resolution (IDR) Statement

Declaration

Attachments

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