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Motor Vehicle Claim Form
 
The Issue of this Form is not an Admission of Liability by Insurer
* = Required information   Policy #:
Please complete and return this claim form as soon as possible, so that your claim will receive prompt consideration by the Insurers.
PLEASE NOTE
1. If anyone holds you responsible for their accident/injury, insist their claim must be in writing.
2. Any communication received must be forwarded to us immediately.
3. Do Not Admit Liability
4. If there is insufficient space or further comment on any area is considered necessary, please use additional pages.
The Insured
  * Company Name  
Name * Surname  
* Address
* Post Code    
* Occupation  
* Phone Private   * Phone Business  
Fax No. * Mobile  
* Email   * Contact Name  
* Are you registered for GST?
* What is your ABN?  
* Have you claimed an input tax credit on the GST amount applicable to this policy?
* Specify amount claimed:  %  
The Insured Vehicle
Year
Make
Model
Type of body
Engine No.
Registration No.
No. of Cylinders
Manual/Automatic
Colour
Carrying Capacity
Tonnes
What accessories were fitted to the vehicle?
Is the vehicle improve/modified in any way?
If yes, specify, indicating improvements/modifications together with costs
For what purpose was the vehicle being used at the time of the accident?
 
Name of registered owner of vehicle
Name of Finance Co. (If under hire purchase or lease)
Contract No.
Has the insured ever made a claim under a motor vehicle policy or been convicted of any offence arising from the use of a motor vehicle?
If so, give details
   
The Driver
Title
Name
Other Name
Drivers Address
Post code
Tel. Private
Tel. Business
Licence No.
State of issue
Expiry Date  dd/mm/yyyy  
Date of Birth  dd/mm/yyyy  
Year licensed
Occupation
Relationship to insured (Spouse, Employee, Friend, etc)
Was the vehicle being used with insured's knowledge and consent?
Approximately how frequently in a period of a year does the driver drive this vehicle?
Does the driver hold motor insurance on any other vehicle?
Had the driver consumed any intoxicating liquor or taken any drugs during 12 hours prior to accident?
If so give particulars
Did the driver undergo a breath analysis test?
If "yes", advise result of test
Did the driver undergo a blood test and/or drug test?
If "yes", advise result of test
Has the driver within the last five years had any insurance or renewal of insurance declined or cancelled or special conditions imposed?
If yes give details
Has the driver within the last five years had an accident, fire or theft involving a motor vehicle and/or made a motor claim against any insurer?
If yes give details.  
Date of Loss Type of Claim
(Theft, Collision, etc)		 Amount of Loss Insurance Company
The Accident
Date of accident  dd/mm/yyyy  
Time    
Day
Place of accident: Street
Town/Suburb
State
Name of nearest cross street
Brief description of accident
Estimate speed of your vehicle at time of impact
Estimate speed of other vehicle at time of impact
Was horn on your vehicle sounded or other warning given?
On what side of the road was your vehicle travelling?
What were the weather conditions?
How many lanes?
Which lane were you travelling in?
What was the condition of the roadway (Sealed, rough, or otherwise?)
Who do you consider responsible for accident?
Give reasons
Did either party admit liability or make any offer of payment?
Which vehicles were towed from the scene?
The other vehicle
Owners name
Address
Postcode
Drivers name
Address
Postcode
Driver’s approx age
Licence No.
Phone No.
Name of insurer of other vehicle
Reg No.
Make/Model of vehicle
Year
Policy No.
Colour
Give particulars of damage to Third Party (A) vehicle
(B) Fixed property
Has any demand for this damage been made against you?
Witnesses
Name Addresses and Telephone numbers of witnesses in insured vehicle
Names, Address and Telephone numbers of independent witnesses
Police
Did a police officer attend the accident?
If “no” state time and date reported to police station
Name of police officer
Police Station
Did police lay any charges against either driver or intimate action may be taken?
Name of driver charged
Nature of charge
Damage to insured vehicle
Was the insured vehicle damaged?
Where can the vehicle be inspected?
Have you obtained a quotation for repairs?
Amount
PLEASE FORWARD QUOTATION WITH THIS FORM  
Name of repairer
Address
Postcode
Telephone No.
Fax No.
Shade in damage to insured vehicle related to this accident. vehicle
Sketch plan of accident plan
 

To avoid unnecessary delay in processing your claim, it is important that you attach documentation to support:

  • ownership of all property claimed, eg. Original invoices, owners manuals, photos, receipts, etc…
  • the repair / replacement of your loss. Eg. Original invoices, receipts, etc… by trade suppliers / repairers – itemising the precise nature of their quotation or work under taken eg. Size, model, type, age, hours, cost of labour, parts, prices…

Agree

Agree

Agree
 
 
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