Claim Form

Claim Form

Motor
Contact Information
Business Name
Contact for claim

First NameLast Name
Contact - Phone Number
Please enter a valid phone number.Format: 0000000000.
Contact - Email
example@example.com
Vehicle Details
Year, Make, Model of insured vehicle
Rego / VIN
Finance on vehicle?
Finance company name
Driver Information
Driver - Name

First NameLast Name
Driver - Address

Street Address

Street Address Line 2
SuburbStatePost Code
Driver - Driver's licence number
Driver - Driver's licence type
Driver - Year's Licenced
Driver - Months Licenced
Driver - Phone Number
Please enter a valid phone number.Format: 0000000000.
Driver - Date of Birth

DayMonthYear
Incident Details
Date & Time of Incident

MonthDayYear
Date
Hour MinutesAM/PM Option
Briefly describe the circumstances surrounding the incident, including the events leading up to it.
Location of Incident
Was the vehicle being used with the full knowledge and consent of the policyholder?
What is the relationship of the Driver to the Policyholder?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident: been involved in any previous motor vehicle accident in the last 5 years?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident: been charged with any offence in relation to the use of a motor vehicle in the last 5 years?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident: had any insurance declined or cancelled, been refused renewal of an insurance or had special terms imposed in the last 5 years?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident: had a drivers license cancelled, suspended, disqualified or committed any driving related alcohol or drug offenses in the past 5 years?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident: committed any criminal offenses?
Was the driver under the influence of any drug or alcohol at the time of the accident?
Please state what drugs or how much alcohol was consumed by the driver in the 12 hours prior to the accident
Did the driver undergo a breath test?
If Yes, what was the reading?
Did anyone suffer injuries?
If “Yes” to any of the above, please give details below:
Speed of insured vehicle at time of claim
Speed of third party vehicle at time of claim
Was the insured vehicle towed and if so, where is it now?
Police report number if applicable
Third Party - details
Third Party - Name

First NameLast Name
Third Party - Address

Street Address

Street Address Line 2
SuburbStatePost Code
Third Party - Vehicle Description
Third Party - Rego / VIN
Third Party - Driver's licence number
Third Party - Phone Number
Please enter a valid phone number.Format: 0000000000.
Third Party - Insurer (if known)
Witness
Witness - Name

First NameLast Name
Witness - Address

Street Address

Street Address Line 2
SuburbStatePost Code
Witness - Phone Number
Please enter a valid phone number.Format: 0000000000.
Damage Assessment
Description of Damage to Insured Vehicle - What and where on vehicle
Description of Damage to Other Vehicles/Property - What and where
Attach photos of the accident scene, damages, and any relevant documents ie. dashcam footage

Cancelof
Please let us know your preferred repairer. If you don’t have one, you’re welcome to choose from the insurer’s approved repairer network below. These repairers usually help the process run more smoothly as they work closely with the insurer.

Allianz: https://www.einsure.com.au/aalrs/repairerlocator/online.html

CGU: https://www.cgu.com.au/partner-repairers

Vero: https://www.vero.com.au/business-car-vehicle-insurance/motor-repairer-network.html

Blue Zebra: https://bzi.com.au/claims-repairer-network

Hollard: https://www.hollard.com.au/customer/claims/repairer-search
Who is your preferred repairer?
Additional Information
Your Bank Details
BSBAccount
Account NameInput Tax Credit %
Declaration:

I declare that the information provided is true and accurate to the best of my knowledge. I understand that providing false information may result in the denial of my claim.
Date

MonthDayYear
Date
Signature
Should be Empty:

Claim Form

Contact Information

Vehicle Details

Driver Information

Incident Details

Third Party - details

Witness

Damage Assessment

Your Bank Details