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 NameAddressPostcodePhone No.OccupationEmail What is your Australian Business Number (ABN)?Are you registered for GST?YesNoTo 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?YesNoIf NO, who is the owner?Insured VehicleMake & ModelYearRego NumberRego Expiry DateColourClass of VehicleSedan or Station WagonVan or Utility up to 2TRigid Vehicle over 2T and up to 5TRigid Vehicle over 5T and up to 10TRigid Vehicle over 10TArticulated Prime MoverBus or CoachLight Construction or Earthmoving PlantHeavy Construction or Earthmoving PlantTrailerOtherTrailer Details (if applicable)MakeTypeYearRegistration No.DriverIf the vehicle was unattended, who was responsible for the vehicle at the time of the loss.SurnameGiven Name(s)AddressPostcodePhone No.Date of BirthGenderMaleFemaleDriver LicenceExpiry DateYears HeldRegistered Owner of VehicleAre you an employee?YesNoIf not, stateHave you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) yearsYesNoIf Yes, please give details including dates and circumstances.Did you consume any alcohol or take drugs during the 12 hours prior to the accident?YesNoIf Yes, what was consumed, in what quantities and when consumed.Did you undergo a breath test or blood test for alcohol or drugs?YesNoIf Yes, what was the result.Did you refuse to undergo any of the above tests?YesNoDamage to Insured VehiclesWas your vehicle damaged?YesNoWas your vehicle towed away?YesNoHave you obtained a repair quote?YesNoRepair quote amount $(Attach Quote)FileIf you are unable to attach a quote, please advise the name of the repairer, their contact details and quote numberName of repairerContact detailsQuote numberIf 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?BusinessPrivateDateTimeVehicle Use:What was the accident location?StreetSuburbPostcodeHow did the accident happen?Who do you consider was at fault?MyselfOther DriverSomething ElseDescribe what / who else was at faultEstimated speed of YOUR vehicle just before the accidentEstimated speed of OTHER vehicle just before the accidentWhat was the condition of the road? Sealed Unsealed Smooth Rough Wet Dry How was visibility?GoodModeratePoorWere there any witnesses to the accident?YesNoIf yes, please provide name/s, address/s and phone number/s.Did Police attend the accident?YesNoPolice StationName/Number of OfficerIf No, state time and date reported to PoliceDid Police indicate who was responsible?YesNoIf Yes, Name of DriverDid Police charge either driver or suggest action may be taken?YesNoChargeDamage 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?YesNoPerson ANameType of InjuryInjured Party (Passenger/Driver)Vehicle (Registration No.)Person BNameType of InjuryInjured Party (Passenger/Driver)Vehicle (Registration No.)Name of DriverDate Name of InsuredDate 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 NameThis field is for validation purposes and should be left unchanged.