Motor Insurance Claim Form To report a claim, please complete this details below and we will contact you as soon as possible to assist you with this matter. Step 1 of 5 20% Your Name* Email Address Contact Telephone* Insured Vehicle DetailsDriver of Insured Vehicle* Driver's Licence NumberDriver's Licence Expiry MM slash DD slash YYYY Driver's Date of Birth MM slash DD slash YYYY Date of Loss DD slash MM slash YYYY Time of Loss : Hours Minutes AM PM AM/PM Location of Loss Type of Vehicle Registration Number* Photo Copy of Drivers Licence, Name, Address, Phone Number, Licence Number, Years Licenced Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB. Description of LossDiagram of Incident Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB. Third Party DetailsThird Party Driver's Name* Third Party Driver's Address Third Party Driver's Contact NumberThird Party Driver's Date of Birth MM slash DD slash YYYY Third Party Driver's LicenceThird Party Driver's Licence Expiry MM slash DD slash YYYY Registration Number of Third Party Claim Number Please indicate if availableThird Party Vehicle Type Accident DetailsAny witnesses?If yes, please fill out the details below.YesNoWitness Name Witness Address Witness NumberDamage to your Vehicle (If so, please advise front, back etc) Damage to Third Party Vehicle (If so, please advise front, back etc) Any photos to Damaged vehicles Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 1 GB. Police Notified?YesNoIf yes, provide police name and station Police Report Number Who do you think is responsible for this incident?* Other Vehicle DetailsCompany NameIf your Vehicle is registered in company name, require ABN number and will be claiming GST component. ABN Number Do you have a recommended repairer?If so, please advise name, address and contact numberRequire quotation for repairs from your repairerYesNoIn the last 5 years have you ever being convicted of an offence? Loss of Licence? Charged? Yes No In the last 5 years ever had a motor accident? Yes No In the last 5 years ever had any loss of demerit points? Or Traffic offences? Yes No Had you consumed alcohol or drugs prior to the accident? Yes No Have you ever been (select all that apply) Convicted of a criminal offence? Had an special conditions imposed on an insurance policy? Had a policy of insurance cancelled or declined by an insurer? Had any traffic offences? Lost your licence, had any suspensions, or conditions imposed on your license? None of the above What is 10 + 8 ?Spam SecurityNameThis field is for validation purposes and should be left unchanged. Δ
