Travellers Autobarn Accident Damage Form

Accident & Damage Form

The Hirer and Your Rental Vehicle
Your Vehicle Registration / Licence No*
Your Rental Agreement Number
Hirer's Name*

First NameLast Name
Hirer's Phone Number
If international please include country code
Hirer's Email*
Hirer's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Hirer's Home Country

Accident Details

Tell us about the Accident
Accident Date*

DayMonthYear
Accident Time*

:HourMinutesAM/PM Option
In your own words describe what happened*
Location of Accident*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Were you the Driver at the time of the Accident?*
Were there any Independent Witnesses or Passengers?*
Did the Police Attend?*
Upload Accident Photos (must be jpg, jpeg, png, gif)

Browse Files
Include photos of the scene, our vehicle and any other vehicles involved Cancelof
Sketch the Accident

Drivers Details

Who was Driving our Vehicle at the Time of the Accident?
Driver's Name

First NameLast Name
Driver's Phone Number
If international please include country code
Driver's Email
Driver's Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's Home Country

Other Vehicles Involved

Who else was involved in the Accident
How many other Vehicles were Involved?*

Witness Details

Contact Details for the Independent Witnesses
How many Independent Witnesses were there?*

Police Details

Contact Details for the Police Officer
Officer's Name

First NameLast Name
Officer's Contact Phone Number
If international please include country code
Officer's Email
example@example.com
Police Station Location
Police Report Number
Did the Police Charge Anyone?
Why was this person charged?

Pursuant to Travellers Autobarn Privacy Policy and the provision of any Privacy Acts the following is brought to your attention:
- This claim form collects personal information about you;
- The information is collected to evaluate your claim;
- The collection of this information is required pursuant to the terms of your insurance policy;
- The failure to provide this information may result in your claim being declined;
- You have the rights of access to, and correction of, this information subject to the provisions of the relevant Privacy Act.
DECLARATION: Note: Failure to provide full and truthful information could result in the claim being declined
- I/We declare that the information given in this form is correct.
- I/We authorise and request the Police to release to Travellers Autobarn copies of any documents held by the Police relating to the incident giving rise to this claim.
- I/We authorise the disclosure of personal information held by any other party regarding this claim.
- I/We agree to Travellers Autobarn releasing to other parties personal information regarding this claim.
- I/We authorise the insurer or its authorised agent to give or obtain from the other insurers or other parties any information relating to any insurance held or claim made.
- I/We authorise you to place details of this claim on the database of Travellers Autobarn where it will be retained and be available to other insurance companies to inspect.
- I/We solemnly declare that the information given & contained in this document is true & correct.
- I/We acknowledge that if any information given is incorrect or has been concealed it may result in the claim being declined.
I HAVE READ THE ABOVE & DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE ANSWERS PROVIDED IN THIS FORM ARE TRUTHFUL
Drivers Signature*

Clear
Date Signed*

DayMonthYear
HourMinutes
Should be Empty:

Accident & Damage Form

Accident Details

Drivers Details

Other Vehicles Involved

Details of the Property Damaged

Details of Other Vehicle Involved

Details of Second Vehicle Involved

Details of Third Vehicle Involved

Witness Details

Witness Details

Second Witness Details

Third Witness Details

Fourth Witness Details

Police Details