Motor Vehicle Claim Form

Your Details

Name*

Business Name / Name of Insured

Policy Number

Phone Number*

Email*

Details of Loss

What time & date did the accident occur?*

Tell us what happened?*

Location where the loss occurred?*

Your Vehicle Details

Vehicle Rego*

Vehicle Year

Vehicle Make

Vehicle Model

Your Driver Details

Driver's Name*

Driver's Date of Birth*

Driver's Licence Number

Years Held Driver's Licence

As a result of the accident did the driver return a positive result to any alcohol or drugs in their system?*

Yes
No
Unsure

In the past 5 years has the driver in the incident had a licence cancelled, disqualified, or suspended?*

Yes
No
Unsure

In the past 5 years has the driver in this incident had an insurance policy declined, cancelled or had any conditions imposed on an insurance policy?*

Yes
No
Unsure

Third Party Details

Third Party Name/s*

Third Party Vehicle Rego*

Third Party Vehicle Make & Model*

Third Party/ies details*

Other Details

Is the vehicle drivable?*

Yes
No
Unsure

Describe the damage to YOUR vehicle?*

Describe the damage to the other vehicle/s or property?*

Do you have a preferred repairer?*

Yes
No

Preferred repairers details?*

Witnesses

Were there any witnesses?*

Yes
No
Unsure

Please provide full details of persons who witnessed the accident*

Further Documentation

Please upload any photos / images you have in relation to the accident

Drop files here or

Max. file size: 32 MB.

Declaration

Please tick to confirm the following to declare:*

The information provided is true and correct
No information has been intentionally withheld
Acknowledge that the completion of this form does not automatically mean that indemnity for this loss has been granted

Signature

This electronic signature will be treated the same as if signed personally.

Email

This field is for validation purposes and should be left unchanged.

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Motor Vehicle Incident Report Form