Motor Claim Form

Name Of Insured

Contact

Contact No.

Email

Policy No

Expiry

Are You Registered For GST Purposes?

Yes
No

ABN

Year

Make

Model

Body Type

Reg No.

Who Is The Registered Owner Of The Vehicle?

Driver Name

DOB

Drivers Address

Licence No.

Class

Expiry

Years Held

Was The Vehicle Used With The Insured's Consent?

Yes
No

If Yes, For What Reason?

Driver's Relationship To Insured

Were The Police Notified?

Yes
No

If No, For What Reason?

Name Of Officer

Police Station

Police Report No.

Date

Did The Police Attend The Scene?

Yes
No

Were Any Charges Laid?

Yes
No

Please Give Details

Did The Driver Consume Any Alcohol Or Drugs During The 12 Hours Before The Accident?

Yes
No

Was The Driver Tested For Alcohol Or Drugs By The Police?

Yes
No

Result

Date Of Occurrence

Time Of Loss

Location

Post Code

Accident: Describe Events Before, During And After The Accident (includes no. of lanes, speed, parked, reversing)

Theft: Describe Events From Time Parked Until Discovered Missing (include who made the discovery and any action taken)

Road Conditions

Wet
Dry
Sealed
Unsealed

Describe What The Vehicle Was Being Used For At The Time

Who Do You Believe Was At Fault And Why?

Was There Any Admission Of Responsibility For The Accident?

Yes
No

If Yes, Give Details

Where Was The Vehicle Stolen From?

Was The Vehicle Locked At The Time?

Yes
No

Were The Key s Duplicated?

Yes
No

Where Were The Keys At The Time Of The Theft?

Who Has A Set Of Keys To The Vehicle?

Was The Vehicle Alarmed Or Fitted With An Immobiliser?

Yes
No

Has The Vehicle Been Recovered?

Yes
No

Is The Vehicle Driveable?

Yes
No

If Vehicle Was Towed, State By Whom.

Where Can Your Vehicle Be Inspected?

Please Attach Any Quotes That Have Been Obtained

Were There Any Witnesses To The Event? (If Yes Complete The Following)

Yes
No

Name Of Witness

Telephone No.:

Address

Post Code

Where Was The Witness?

Vehicle Year

Make

Model

Registration No.

Colour

Owner's Name

Address

Post Code

Contact No.

Driver's Name

Address

Post Code

Contact Number

Describe The Damage To Other Vehicle Or Property?

Name of Other Party’s Insurance Company Policy No.

Have You Or The Driver Had Any Insurance Or Renewal Of Insurance Declined Or Cancelled Or Special Conditions Imposed In The Last 5 Years?

If Yes, Give Details:

Have You Or The Driver Been Charged Or Convicted Of Any Criminal Offence?

Yes
No

If Yes, Give Details

Have You Or The Driver Had An Accident Or Made A Claim On A Motor Vehicle Insurance Policy In The Last 5 Years?

Yes
No

If Yes, Give Details

Have You Or The Driver Ever Been Convicted Of Any Driving Offences (such as speeding, disobeying traffic lights etc..) In The Last 5 Years?

Yes
No

If Yes, Give Details

Please Attach Any Relevant Documents, Including Photos, Drawings Of The Incident, Letters Or Demand etc.

What is 3 X 2 *

GST

Vehicle Details

Drivers Details

Details of Accident or Theft

Theft:

Witnesses:

Third Party Details:(Please complete the following if any other Vehicles were involved or other property damaged)

History: