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      Page 1. Insured Details

      Insured Name


      Phone No.

      Your Email

      Policy Number


      Are you registered for GST purposes?


      Are you entitled to claim GST on replacement of your motor vehicle?

      Please advise

      Page 2. Insured Drivers Details



      Date of Birth

      Licence No.

      Licence Expiry Date

      Years Licenced

      Driving History

      List any restrictions on the license

      Did the driver drink any alcohol, or take any drugs or medication 12 hours prior to the

      What did the driver drink or what drugs did the driver take?

      Has the driver within the past 5 years been convicted of motoring offences (other than
      parking) or disqualified from driving?

      Please state the details.

      Page 3. Insured Driver's Vehicle Details





      Page 4. Vehicle

      Single VehicleMultiple Vehicle

      Third Party Vehicle and Driver Details

      Third Party Vehicle Details





      Third Party Driver Details



      Phone Number

      Insurance Company

      Insurance Policy Number

      Licence No.

      Accident Details

      Date of Incident

      Time of Incident

      Address of Incident

      Accident Description. Describe 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?

      What were the weather conditions at the time of the accident?

      At the time of the accident what was the approximate speed before braking?

      Is the insured vehicle in drivable condition?

      Were there Police or Firefighters called?

      Report Number

      Name of Station

      Towing Company Name

      Towing Company Phone

      Upload Towing Docomuments

      Repairer Details

      Name of Repairer


      Upload quotes, invoice, images of accident

      Page 5. Payment Details

      To assist with prompt reimbursement, please provide your bank details

      Account Name


      Account Number


      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.

      Please add your Digital Signature here


      Print Name

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