Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged beforehand, no repairs or alterations to the damaged vehicle should be made unless approved by your insurance broker.Policy NumberClient Ref No.InsuredInsured’s Name Address PostcodePhone No.Occupation Email What is your Australian Business Number (ABN)?Are you registered for GST? Yes No To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?*Are you the sole owner of the insured vehicle? Yes No If NO, who is the owner? Insured VehicleMake & Model YearRego NumberRego Expiry Date Colour Class of Vehicle Sedan or Station Wagon Van or Utility up to 2T Rigid Vehicle over 2T and up to 5T Rigid Vehicle over 5T and up to 10T Rigid Vehicle over 10T Articulated Prime Mover Bus or Coach Light Construction or Earthmoving Plant Heavy Construction or Earthmoving Plant Trailer Other Trailer Details (if applicable)Make Type YearRegistration No.DriverIf the vehicle was unattended, who was responsible for the vehicle at the time of the loss.Surname Given Name(s) Address PostcodePhone No.Date of Birth Gender Male Female Driver Licence Expiry Date Years Held Registered Owner of Vehicle Are you an employee? Yes No If not, state Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years Yes No If Yes, please give details including dates and circumstances. Did you consume any alcohol or take drugs during the 12 hours prior to the accident? Yes No If Yes, what was consumed, in what quantities and when consumed. Did you undergo a breath test or blood test for alcohol or drugs? Yes No If Yes, what was the result. Did you refuse to undergo any of the above tests? Yes No Damage to Insured VehiclesWas your vehicle damaged? Yes No Was your vehicle towed away? Yes No Have you obtained a repair quote? Yes No Repair quote amount $(Attach Quote)FileMax. file size: 2 MB.If you are unable to attach a quote, please advise the name of the repairer, their contact details and quote numberName of repairer Contact details Quote number If not driveable, what is the full address where the vehicle can be inspected? Phone No.Describe in detail where the damages appear on your vehicle.Accident DetailsBusiness or private? Business Private Date Time Vehicle Use: What was the accident location? Street Suburb PostcodeHow did the accident happen?Who do you consider was at fault? Myself Other Driver Something Else Describe what / who else was at fault Estimated speed of YOUR vehicle just before the accident Estimated speed of OTHER vehicle just before the accident What was the condition of the road? Sealed Unsealed Smooth Rough Wet Dry How was visibility? Good Moderate Poor Were there any witnesses to the accident? Yes No If yes, please provide name/s, address/s and phone number/s.Did Police attend the accident? Yes No Police Station Name/Number of Officer If No, state time and date reported to Police Did Police indicate who was responsible? Yes No If Yes, Name of Driver Did Police charge either driver or suggest action may be taken? Yes No Charge Damage to Other Vehicle or PropertyVehicle or Property No. 1Name of other driver: Age:PhoneLicence No: Vehicle Make & Model: Rego No: Name of Registered Owner: Address: PhoneThe Other Insurance Company: Policy Number: Description of DamageVehicle or Property No. 2Name of other driver: Age:PhoneLicence No: Vehicle Make & Model: Rego No: Name of Registered Owner: Address: PhoneThe Other Insurance Company: Policy Number: Description of DamagePersonal InjuriesWas anyone injured in the accident? Yes No Person AName Type of Injury Injured Party (Passenger/Driver) Vehicle (Registration No.) Person BName Type of Injury Injured Party (Passenger/Driver) Vehicle (Registration No.) Name of Driver Date MM slash DD slash YYYY Name of Insured Date MM slash DD slash YYYY How To Make A Motor Vehicle ClaimWhether at fault or not and to avoid delay, it is easier to claim on your Insurer and let them recover for you. Here are the steps to be taken: - 1. Obtain a quotation from a reputable repairer. 2. The repairer will usually arrange the assessment and for this you must: - a) Compete a claim form, b) Supply a copy of your licence to be left with the claim form at the repairers. 3. On the day of the assessment (to be pre-arranged with you), the vehicle should be left all day with your repairer, repairs should be authorised on that day and work can commence. You will pay your excess to the repairer when collecting the repaired vehicle. If you are not at fault: - •Your excess is recoverable •Car hire may be paid for, if a business registered vehicle, but not necessarily all costs. Please note, the refund of excess and car hire is paid by the third party or their Insurer and this usually takes between 3-6 months. If not refund received after 6 months, you can: - •Follow this up yourself by contacting your Insurer •Contact our office and ask our assistance. 4. In the event of a total loss, the market value will be determined by the assessor. At times you may not agree on this figure, however, it is your prerogative to obtain another valuation. We can advise. 5. If the vehicle has been stolen, your Insurer will apply for a Police report. They will generally wait for 4-6 weeks before settling the claim in the event the vehicle is recovered (80% usually are recovered albeit not in the condition when last seen by the owner). 6. If your vehicle is not damaged or damage is minor but you have caused damage to an third party and the accident is your fault, a claim form must be completed and sent to our office with a copy of your licence and excess if applicable, and then forward any letters of demand with quotations.Please type your name below to agree to our terms PhoneThis field is for validation purposes and should be left unchanged.
