Vehicle Claim Step 1 of 5 20% Page 1. Insured DetailsInsured Name(Required)Address(Required)Phone(Required)Email(Required) Policy Number(Required)GSTAre you registered for GST purposes? Yes No Page 2. Insured Drivers DetailsNameAddressDate of Birth Licence No.Licence Expiry Date Years LicencedDriving HistoryList any restrictions on the licenseDid the driver drink any alcohol, or take any drugs or medication 12 hours prior to the accident? Yes No Has the driver within the past 5 years been convicted of motoring offences (other than parking) or disqualified from driving? Yes No Page 3. Insured Driver's Vehicle DetailsRegoYearMakeModel Page 4. Vehicle Single Vehicle Multiple Vehicle Third Party Vehicle and Driver Details RegoYearMakeModelThird Party Driver DetailsNameAddressPhoneInsurance CompanyInsurance Policy NumberLicence No.Untitled Accident DetailsDate of Incident Time of Incident Hours : Minutes AM PM AM/PM Address of IncidentAccident DescriptionDescribe in detail the circumstances leading up to the accident and how the accident happened. It is important to be as accurate as you can. Please tell us the facts, even if they aren't in your favor.What were the road conditions at the time of the accident?Sealed Roadway - Wet RoadSealed Roadway - Dry RoadUnsealed Roadway - Wet RoadUnsealed Roadway - Dry RoadWhat were the weather conditions at the time of the accident?FineOvercastRainingStormHailOther ConditionsAt the time of the accident what was the approximate speed before braking?Is the insured vehicle in drivable condition? Yes No Were there Police or Firefighters called? Yes No Drivable Condition Clear drawing Drivable Condition File Drop files here or Select files Max. file size: 128 MB. Repairer DetailsName of RepairerPhoneSubmit supporting images and documents Drop files here or Select files Max. file size: 128 MB. Page 5. Payment Details To assist with prompt reimbursement, please provide your bank detailsAccount Name(Required)BSB(Required)Account Number(Required)Declaration I/ We declare that the best of my/our knowledge and belief the information in this form is true and correct and I/we have not withheld any relevant information. I/we consent to the insurance company using my personal information I/we have provided on this form for the purpose of processing my claim. I/we understand that if I/we choose not to provide required details, this is my/our choice, however the insurance company may not be able to process my claim. I/we consent to the insurance company disclosing my personal information to other insurers, an insurance reference services or as required by law. I/we consent to the insurance company also disclosing my personal information about me, from investigators or legal advisors.SignatureYour NameYour NameYour NameYour NameDate Print Name
