Motor Vehicle Insurance Claim This Motor Vehicle Claim form can be installed to your WordPress website 'as is' or with further customisation to the question set. When we install to your website the colours and styling will be amended to suit your website. The form system sends an email notification to the email address(s) that you nominate and the customer can receive a copy also. Data from every submission is saved to your WordPress Admin and you can access these at any time with exporting functions available. To demo this form, please fill in your email address here, you will receive a copy of the demo form via email. Email for Demo Delivery* Motor Vehicle Claim Notification FormPolicy NumberClient Ref No.InsuredInsured’s NameAddressPostcodePhone No.Email Are you registered for GST? Yes No What is your Australian Business Number (ABN)?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 & ModelYearRego NumberRego Expiry DateColourDo you want to add Trailer Details?* Yes No Trailer Details (if applicable)MakeTypeYearRegistration No.This field is hidden when viewing the formEnd SectionDriverSurnameGiven Name(s)AddressPostcodePhone No.Date of BirthDriver LicenceExpiry DateYears HeldGender Male Female 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: 8 MB.If 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, Full address where the vehicle can be inspected?Phone No.Describe in detail where the damages appear on your vehicle.Accident DetailsAt the time of the accident was the vehicle being used for business or private use? Business Private Date of accidentTime of accidentStreetSuburbPostcodeHow did the accident happen?Who do you consider was at fault? Myself Other Driver Something Else Describe 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? 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 StationName/Number of OfficerIf No, state time and date reported to PoliceDid Police indicate who was responsible? Yes No If Yes, Name of DriverDid 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:Phone No.The 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 ANameType of InjuryInjured Party (Passenger/Driver)Vehicle (Registration No.)Person BNameType of InjuryInjured Party (Passenger/Driver)Vehicle (Registration No.)PrivacyThe Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.Internal Dispute Resolution (IDR) Statement Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).Declaration1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.Name of DriverDate MM slash DD slash YYYY Name of InsuredDate 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 thi9s 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 provide bank details in order for your claim payment to be settled via EFT.BSB Number:Bank Account Number:Name of Bank:Account Holder NamePlease type your name below to agree to our terms CommentsThis field is for validation purposes and should be left unchanged.
