Insurely Motor Vehicle Claim Form

Area Code Phone Number

2. Is this vehicle subject to a finance arrangement of any kind?

3. Has the vehicle or engine been modified from the maker's standard specification?

4. Is there any other insurance on the vehicle or accessories?

Address

Street Address Line 2

Suburb

Area Code Phone Number

1. Did the driver have the owners permission to drive the vehicle?

4. Has the driver ever been refused vehicle insurance or had a policy cancelled or not renewed?

(a) Been involved in a motor accident?

(b) Been convicted or a driving offence or issued with an offence or infringement notice (including speeding

1. When did the accident happen?

Area Code Phone Number

1. Did anyone get hurt in the accident?

4. Did anyone admit liability?

5. Did the police attend the accident?

Area Code Phone Number

1. THE INSURER IS AUTHORISED TO MOVE THE VEHICLE TO A CLAIMS ASSESSING CENTRE FOR EXAMINATION AND ASSESSMENT

2. Material Facts

(a) All information given to the insurer in connection with this claim (whether oral or written) is true and correct; (b) No information relevant to the claim is omitted. (a) My personal information collected by insurer in connection with this claim may be: (i) disclosed to other members of the insurance industry and Insurance Claims Register Limited; (ii) disclosed to parties repairing or replacing the subject matter of the claim; (iii) disclosed to parties who have a financial interst in the subject matter of policy; (iv) used by insurer to advise me of its other services (b) My personal information held by any other parties in connection with this claim may be disclosed to the insurer.

Please note: We gather information about you (including your claims history) to consider your claim. The terms of your insurance policy require you to supply this information, and if you do not provide it, or if you provide any flase or untrue information, we may decline your claim.

Your claims history is passed onto, and held by, Insurance Claims Register Limited. This enables other insurers you deal with to access it, and prevents fraudulent claims.

PART A: THE INSURED

PART B: THE INSURED VEHICLE

PART C: DETAILS OF DRIVER OR PERSON IN CHARGE OF INSURED VEHICLE

PART D: DETAILS OF ACCIDENT

PART E: DAMAGE TO THE INSURED VEHICLE

PART F: OTHER VEHICLE OR PROPERTY DAMAGED

PART G: LIABILITY FOR THE ACCIDENT

PART H: WITNESSES TO THE ACCIDENT

PART I: DECLARATION AND SIGNATURE

SIGNED BY THE DRIVER

ON BEHALF OF ALL APPLICANTS