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 Type of Incident * 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 There a Witness? YesNo 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. Police Report Upload or drag files here. 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.
