CRI MV Claim Form

MOTOR VEHICLE CLAIM (NONTHEFT)

The issue of this form does not constitute an admission of liability on the part of the insurer.
Please complete all sections of this claim form and return with the following documents:

Quotation from your chosen repairer or preferred repairer detailsRental agreementRental breach: NORental breach: YES - If YES, please provide detail and a copy of the terms and conditions of rentalAttach any other information or correspondence you may have received in relation to this claim.
POLICY NUMBER
RENTAL AGREEMENT NUMBER
A. RENTAL COMPANY DETAILS
Rental Company Name
Postal Address

Street Address

Street Address Line 2

SuburbState

Postcode
What is your ABN?
Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy?

NOYES
Will you be claiming an amount less than 100%?

NOYESOther
Business Contact Number
Email Address
example@example.com
B. RENTAL VEHCILE DETAILS
Make of Vehicle
Mth/Year
Registered No.
Model
Colour
Odometer Reading
Engine No.
Chassis/VIN No.
Registered Owner
Address

Address

Street Address Line 2

SuburbState

Postcode
Do you owe finance on your vehicle?

NOYES
Name of Lender
Account Number
State any non standard accessories/modifications to vehicle
What was the intended operating radius of the journey?
State time & place journey commenced & intended desitination
C. RENTER DETAILS (details of the person the rental agreement is signed under with Evee)
Full Name (Block Letters)

First NameLast Name
Address

Street Address

Street Address Line 2

SuburbState

Postcode
Contact Number
Email
example@example.com
Is the renter self insured? (YES or NO. If YES give details)
D. DRIVER DETAILS (FOR PARKED OR UNATTENDED VEHICLES, DRIVER OR CUSTODIAN AT THE TIME OF LOSS)
Relationship to Renter
please select the option that is applicable to you

owner driver at the time of the incidentrenter driver at the time of the incident
Full Name

Given Name(s)Surname
Address

Street Address

Street Address Line 2

SuburbState

Postcode
Licence No
State
Licence Expiry Date

DayMonthYear
Date
DOB

DayMonthYear
Date
How long has the driver been licensed for this type of vehicle?
Years
Contact Number
Email
example@example.com
Did the driver drink any alcohol or take any drugs in the last 24 hours prior to the accident? If YES, give details
Did the driver undergo a breath test, breath analysis or blood test? If YES, give details
What was the reading? (Please attach a copy of the certificate)
E. INCIDENT DETAILS
Date

DayMonthYear
Date
Day
Time
Where did the incident happen?

Street Address

Nearest Cross Street

SuburbState

Postcode
Describe how the incident occurred?
Speed
kms
Road surface

DryWetSealedUnsealed
At the time of the incident the insured vehicle was:

ParkedStationaryMoving
Traffic Controls

NoneStop signTraffic lightsRoundaboutGive way signOther
Number of vehicles involved
Who was at fault?
full name details
In the below Diagram, please see below instructions:
Sketch Diagram of Accident
F. DAMAGE TO YOUR VEHICLE
Are you claiming damage to the rental vehicle?

NOYES
Was the vehicle towed?

NOYES, give details
Name of the Towing Company
Telephone
Where was it towed?
Where is the vehicle now?
Shade areas of damage being claimed Indicate point of impact (X)
G. POLICE
Did a Police Officer attend the accident scene, or did you report the incident to the police?

NOYES
Name of Officer
Police Event Number
Station
Date of report

DayMonthYear
Date
Did the Police indicate who was responsible?

NOYES
If you answered YES to the above, please give details below:
Name of person to be charged or cautioned
Nature of charge or caution
H. PASSINGER(S) - All passingers in the rental vehcile at the time of the accident
Passenger 1
Passenger 2
Passenger 3
I. WITNESS(ES) - All independent witnesses, not passengers in the rental vehicle at the time of the accident
Witness 1
Witness 2
J. DETAILS OF OTHER VEHICLE (third party details)
Full Name

Given Name(s)Surname
Address

Street Address

Street Address Line 2

SuburbState

Postcode
Registered No.
Make of Vehicle
Model
Contact Number
Licence Number
DOB

DayMonthYear
Date
Was the owner in the vehicle at the time of the accident?

NOYES, give details below
Provide details below
Insurance Company
Policy or Claim No
K. DAMAGE TO OTHER VEHICLE
Sketch Diagram: Shade areas of damage being claimed Indicate point of impact (X)
L. PRIVACY
We respect your privacy and we comply with the Privacy Act and the National Privacy Principles. A copy of our Privacy Statement is available at any of our offices or online at www.CGU.com.au

Complaints Procedure

If you do not agree with any decision we make in relation to the Policy, please write to us stating what you disagree with and why. We will then resolve or attempt to resolve your complaint immediately, or we will refer the matter to our Internal Dispute Resolution Committee (IDRC If you are not satisfied with a Claim decision by the IDRC, the matter may be referred to an independent dispute resolution body, Australian Financial Complaints Authority (AFCA), provided the matter falls within their jurisdiction.

Australian Financial Complaints Authority
Freecall 1800 931 678
Post: GPO BOX 3, Melbourne Victoria 3001
Website: www.afca.org.au
Email: info@afca.org.au

The Insurance Contracts Act 1984 (as amended) requires you to provide all information which CGU may reasonably require, and stipulates that any omission may adversely affect the cover under your Policy. If you would like more information on your Duty of Disclosure (or any other aspect), please contact your broker or nearest CGU Insurance office.
M. DECLARATION AND AUTHORISATION
The information and answers given above are true, correct and complete in every detail.

1.I/We understand the claim may be refused if the information is not true or is withheld.

2. I/We authorise CRI to give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the Insured or Renter's credit or insurance history as well as insurance claims information obtained during the course of this contract.
Signature of Renter

Clear
Date

DayMonthYear
Date
Signature of Insured

Clear
Date

DayMonthYear
Date
PLEASE CHECK THAT THIS FORM HAS BEEN FULLY COMPLETED AS ANY OMISSIONS MAY DELAY YOUR CLAIM.
Should be Empty:

MOTOR VEHICLE CLAIM (NONTHEFT)