CRI MV Claim Form

Please complete all sections of this claim form and return with the following documents:

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?

Will you be claiming an amount less than 100%?

Other

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

Street Address Line 2

SuburbState

Postcode

Do you owe finance on your vehicle?

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

Full Name

Given Name(s)Surname

Address

Street Address

Street Address Line 2

SuburbState

Postcode

Licence No

State

Licence Expiry Date

Date

DOB

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

Day

Time

Where did the incident happen?

Street Address

Nearest Cross Street

SuburbState

Postcode

Describe how the incident occurred?

Speed

kms

Road surface

At the time of the incident the insured vehicle was:

Traffic Controls

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?

Was the vehicle towed?

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?

Name of Officer

Police Event Number

Station

Date of report

Date

Did the Police indicate who was responsible?

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

Date

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

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

Date

Signature of Insured

Date

PLEASE CHECK THAT THIS FORM HAS BEEN FULLY COMPLETED AS ANY OMISSIONS MAY DELAY YOUR CLAIM.

MOTOR VEHICLE CLAIM (NONTHEFT)