Claim Form

CLAIM LODGEMENT
Agent
Let's Get Started
How can we help?
Claim Reference Number
e.g NAT654321
Describe how we can help
Please state what kind of assistance you need
What best describes this claim?
How severe is the damage to your car?
Damage Photo (broken)
Damage Photo

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Is your car driveable?
Who Caused Accident?
What would you like us to do?
Do you require hire car?
(c) National Cover Pty Ltd 2024 ABN 74 639 621 480 | Corporate Authorised Representative of Shanebridge Pty Ltd ABN 16 011 049 899, AFSL 245566.
288 Musgrave Road, Coopers Plains, QLD 4108
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Accident Details
State Where Accident / Theft / Event Happened*
Date of Accident / Theft / Event*

DayMonthYear
Time of Accident / Theft / Event (if known)

:HourMinutesAM/PM Option
How did the accident / theft / event happen?*
Was this accident a "rear ender"?*
Did vehicle involve "changing lanes"?*
Was your car parked at time of accident?*
Location of Accident / Theft / Event*
Please decsribe in detail the street address or nearest intersection
Event Diagram
Accident / Event Scene Photo (if exists)

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Diagram Instructions
1. Take a screenshot of accident location on Google Maps. 2. Upload copy of screenshot to diagram. 3. Draw over the screenshot showing what happened.
(c) National Cover Pty Ltd 2024 ABN 74 639 621 480 | Corporate Authorised Representative of Shanebridge Pty Ltd ABN 16 011 049 899, AFSL 245566.
288 Musgrave Road, Coopers Plains, QLD 4108
insurance@nationalcover.com.au. Privacy Policy | General Advice Warning

Other Party Details
Other Driver Name

First NameLast Name
Other Driver Rego Number
Other driver phone number
Other Driver Address
Other Driver Licence Photo (broken)
Other Driver Licence Photo

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Other Driver Insurer
Other Driver Claim Number
(c) National Cover Pty Ltd 2024 ABN 74 639 621 480 | Corporate Authorised Representative of Shanebridge Pty Ltd ABN 16 011 049 899, AFSL 245566.
288 Musgrave Road, Coopers Plains, QLD 4108
insurance@nationalcover.com.au. Privacy Policy | General Advice Warning

Claim Authorisation
Customer Service Options
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We want to provide you the best claims experience possible. If you preffer better communication with us about your claim, please consider adding us on Whatsapp by clicking the image below. Alternatively, proceed to clicking "Submit" and we will be in contact via email.
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CLAIM LODGEMENT