Claims Form Policyholder Information Full Name Insured Name (if different from above) ABN / ACN Email Phone Number Address Policy Number (if known) Details of Loss or Damage Date of Loss or Damage Time of Incident MorningAfternoonEveningNightUnknown Type of Incident Motor VehicleProperty DamageTheftLiabilityOther Estimated Cost of Repair or Replacement (if known) Incident Location (Provide the address of the incident location, along with a description of the specific area) Incident Description Description of Loss or Damage Was this reported to the Police? YesNo Any injuries involved? YesNo Was there a witness? YesNo Are you aware of any other parties that may claim against you? YesNo Injury summary Did the driver undergo alcohol or drug testing by attending police? YesNo Name of Officer Police report number Police Station Report Date Police Report Number (attach copy if possible) Police Report Upload or drag files here. Vehicle Registration Vehicle Year of Manufacture Vehicle Make and Model Are you the registered owner of the vehicle? YesNo Owners details Is there any finance owing on the vehicle? YesNo Road Conditions at time of incident DryWetDayNightOther Drivers Name Drivers DOB Drivers Phone Drivers Email Drivers Address Licence State NSWQLDVICWASATASACTNTOther Licence Number Licence Expiry Number of years held Relationship to Insured Was the vehicle being used with the insureds consent? YesNo Had the driver consumed alcohol or drugs within 12 hours prior to the incident? YesNo Provide details of alcohol or drug use Was your vehicle towed, if yes, where is it now? Preferred Repairer Details Supporting Documents Upload or drag files here. Additional information can be sent direct to your broker. Witness Details Witness 1 Full Name Phone Number Email Witness 2 Full Name Phone Number Email Declaration Signature Name of Person Signing Date The information and answers given above are true, correct and complete in every detail. I/We understand the claim may be refused if information is not true or is withheld.
