Motor Vehicle Claim Form

Motor Vehicle Claim Form

Please ensure you complete the form with as much details as possible
1. Insured or Company Details
Insured Name *
Policy Number
Contact Person

First Name Last Name
Phone Number *

Area Code Phone Number
E-mail *
Are you registered for GST *

Yes No
Do you have an ABN *

Yes No
If Yes, ABN Number
2. Vehicle Details

Vehicle Details *

	Details
Year
Make
Model
Registration Number

Use of vehicle at the time of incident *

Personal Business Other
If "Other" - Please specify
3. Driver Details
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

Suburb State

Post Code
Phone Number *

Area Code Phone Number
Date of Birth *

Day Month Year
dd-mm-yyyy

Please advise *

	Details
Drivers License #
Class Of License
Expiry Date
Driving Experience (Years)

Did the driver consume any alcohol/drugs within 12 hours prior to the collision? *

Yes No
If Yes, please advise the type and quantity
Has the Drivers License been suspended or cancelled in the last 5 years? *

Yes No
If yes, please explain when and why
Did the driver undergo a breath or blood test following the accident? *

Yes No
If yes, please state the result
Please provide full details of damage to your vehicle (Attach additional docs on completion of form) *
No repairs or alterations to the damaged vehicle should be made until Insurers have approved repairs. Failure to do so could result in your Insurer being prejudiced and any costs which are not assessed as fair and reasonable will not be covered by Insurers meaning an out of pocket cost to yourself.
4. Details of The Accident
Date / Time of Accident *

Day Month Year
dd-mm-yyyy Hour Minutes AM/PM Option
Please provide a detailed description of how the accident occurred *
What were the conditions at the time of the accident? (Weather, lighting and condition of road) *
Was your vehicle towed from the accident scene

Yes No
If Yes, name of towing company
If No, please advise the location of the vehicle

Location

Street Address

Suburb State

Post Code
Is your vehicle currently at a repair shop

Yes No
If yes, name and address of Repairer

Repairer

Address

Suburb Sate

Post Code
5. Third Party Details

If no third party involved please leave blank
Drivers Name
Address

Street Address

Street Address Line 2

Suburb State

Post code
Phone Number

Area Code Phone Number
Email
example@example.com
Drivers License No
Date of Birth

Day Month Year
dd-mm-yyyy

Vehicle Details

	Third Party Details
Year
Make
Model
Rego Number

6. Theft of Vehicle

(Yes is required for all malicious damage or theft/burglary claims)
Has your vehicle been stolen

Yes No
If Yes, Location or address where the theft occurred.
7. Witness Details

(Witnesses cannot be friends, family or someone who you know)
Name

First Name Last Name
Address

Street Address

Street Address Line 2

Suburb State

Post Code
Email
example@example.com
8. Police Involvement
Did the police attend the scene of accident?

Yes No
If no, was the incident reported to the police?

Yes No
Please provide details

Police Officer

Police Station

Report Number Phone Number

Date of Report No
Declaration
Signature *

Clear
Name *

First Name Last Name
Date & Time
Please upload any documentation to assist with this claim eg: photos of accident, police report etc

Browse Files

Cancel of
Should be Empty:

Motor Vehicle Claim Form

1. Insured or Company Details

2. Vehicle Details

3. Driver Details

4. Details of The Accident

5. Third Party Details

6. Theft of Vehicle

7. Witness Details

8. Police Involvement

Declaration