MOTOR CLAIM FORM
Motor vehicle insurance
Name
*
First Name
Last Name
Address
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
I would you like to direct this request to a particular OVIB broker
Broker's name
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VEHICLE & DRIVER INFORMATION
Vehicle details
*
I.e.. Year, make & model
Vehicle registration
*
Is the driver the same as the policy holder listed above?
*
Yes
No
Driver name
*
First Name
Last Name
Driver contact details
*
If different to your contact details above
Driver date of birth
*
-
Day
-
Month
Year
Licence Number
*
Licence state of issue
*
Please Select
VIC
NSW
QLD
TAS
SA
WA
NT
ACT
Licence class
*
Please Select
Full driver licence
Heavy vehicle licence
Probationary licence
Learner permit
Licence expiry
*
-
Day
-
Month
Year
What year did you obtain your licence?
Had you consumed any drugs or alcohol 12 hours prior to the accident?
*
Yes
No
Please provide further details
Was either driver asked to take a blood / breathalyser test?
*
Yes
No
Blood / breathalyser test
*
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INCIDENT DETAILS
Date of accident
*
-
Day
-
Month
Year
Approximate time of accident
*
Minutes
AM
PM
AM/PM Option
Address where damage occurred
*
E.g. Great Alpine Rd OVENS
What happened?
*
Was the vehicle parked at the time of damage?
*
Please Select
Yes
No
Is the vehicle drivable?
*
Please Select
Yes
No
Was the vehicle towed?
*
Yes
No
If yes, location of vehicle now
Address
Where is your vehicle damaged?
*
E.g. left side front panel etc
What damage has your vehicle sustained?
*
Do you have a preferred repairer?
*
Yes
No
Have you obtained a quote for repairs?
*
Yes
No
If yes, name and address of repairer
Name & Address
Were any of your personal effects damaged?
*
Yes
No
If so, please list items below
Does your vehicle have any pre-existing damage?
*
Yes
No
Did the police or fire brigade attend the incident?
*
Police
Fire Brigade
No
If yes, please provide the officer's name and station
E.g. Sargent John Smith, Bright Police Station
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Were there any third parties involved in the incident?
*
Yes
No
Yes, but unknown
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THIRD PARTY DETAILS
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
Vehicle details
I.e.. Year, make & model
Vehicle registration
Insurer name
Policy number
Description of damage to third party's property
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Were there any witnesses to the incident?
*
Yes
No
Unknown
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WITNESS DETAILS
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Address
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SETTLEMENT DETAILS
ABN
Are you registered for GST?
*
Yes
No
Have you claimed, or do you intend to claim an input tax credit on the GST applicable to this policy?
*
Yes
No
Is the amount you claimed, or intend to claim less than 100% of the GST applicable to the premium?
*
Yes
No
Specify the percentage amount claimed or intended to be claimed
*
Is your vehicle suspected to be a total loss?
*
Yes
No
Do you owe money on the vehicle?
*
Yes
No
Finance details
*
If so, your insurer will require registration papers and finance pay-out figures, if you have those documents available you can upload below, otherwise you will need to provide these at a late date
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*
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