Motor Vehicle Claim Form

Motor Vehicle Claim Form

Please fill out the form below to submit your insurance claim for motor vehicles.
Insured's Full Name*

First NameLast Name
Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Residential Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Policy Number
Date of Incident or Event*

MonthDayYear
Date
Description of Incident or Damage*
Upload Supporting Documents (e.g., photos, reports, receipts)

Cancelof

Occupation
Australian Business Number (ABN)
Are you registered for GST?

YesNo
To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium (%)?
Are you the sole owner of the insured vehicle?

YesNo
If No, who is the owner?

Driver

For parked or unattended vehicles, Driver = Vehicle custodian at the time of loss.
Driver's Full Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Drivers License Number*
Expiry Date
Years Held
Registered owner of the vehicle?

YesNo

Damage to Insured Vehicles
Was your vehicle damaged?

YesNo
Was your vehicle towed away?

YesNo
Have you obtained a repair quote?

YesNo
Amount $
If not drivable, where can the vehicle be inspected? (Full Adress & Phone Number)
Show the damaged area to your vehicle on the following diagram.

Did the police attend the accident?

YesNo
If YES, Police station
Name/Number of officer
If NO, state the time and date reported to the police.
Did the Police indicate who was responsible?

YesNo
If YES, name of driver?
Did the Police charge either driver or suggest action may be taken?

YesNoCharge

	Name	Type of injury	Injured Party (Passenger/Driver)	Vehicle (Registration No.)
1
2
3
4

I/We declare that to the best of our knowlegde these particulars are truthful, accuarte and complete.
Date*

MonthDayYear
Date
Should be Empty:

Insured Vehicle