Motor Claim Form

Motor Claim Form

Please complete this claim form so that we can get your claim moving
By submitting this form, you consent to the collection of your personal information for the purpose of assisting with your insurance claim and its disclosure to the relevant insurer to assess and manage your claim. Your information will be handled in accordance with the repX Privacy Policy.

To avoid delays in the assessment process, please submit the requested information as soon as possible.
Claim Number (if known)
1. Details of Policy Holder
Name of Policy Holder
Please provide your registered company name if applicable
Address of Policy Holder

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Details
First Name
Last Name
Email
example@example.com
Phone Number

Area CodePhone Number
Broker Email
If unknown, use info@remingtons.com.au
Policy Number
Insurer
Expiry Date

MonthDayYear
Date

2. Insured Vehicle Details
Make
If 'Other', please provide the Make
Model
Year
Registration No.
VIN
At the time of the accident was the vehicle being used for business or carrying any goods?
Please provide details of the business being carried out or goods being carried
Was your vehicle damaged?
Do you know the repairer you are going to use?
Repairer company name
Please attach any photos of damage to your vehicle

Cancelof

Were any of the following traffic controls present at the scene of the accident?

Declaration
I, {typeA181} {typeA182}, confirm that the information provided is true and correct to the best of my knowledge and understand it will be provided to the insurer to assist with my claim.
First Name
Last Name
Position
Date

DayMonthYear
Date
Signature
Should be Empty:

1. Details of Policy Holder