Motor Vehicle Claims Form

All required fields are marked with an asterisk *

Insured/Owner of Vehicle - Best Contact Name

First Name

Last Name

Policy Number

Best Contact Phone

Best Contact Email

Registration Number

Is there any damage to your vehicle?

Is the vehicle driveable?

Where is the damage located?

Do you think the vehicle is a total loss?

Date of Incident

YYYY

Time of Incident

Please enter '0' (zero) for 'second' to avoid error on submission.

Hour

Minute

Second

Location of Incident

Please describe in detail how the accident occurred?

ABN

Driver of Vehicle - Driver’s Name

First Name

Last Name

Driver’s Date of Birth

YYYY

Driver's Contact Phone

Driver's Contact Email

How long has the driver held this licence?

Had driver consumer any drugs or alcohol in the previous 12 hours?

Has the driver ever had their licence cancelled or suspended?

Has the driver ever had insurance refused?

Does the driver have any restrictions on their licence?

Other Driver/Vehicle Details - Phone Number of Driver

Email of Other Driver

Address of Other Driver

Make & Model of Other Car

Other Vehicle’s Registration Number

Other Information - Did the Police attend the accident seen or was the accident reported to the Police?

Is there any damage to Property (Other than vehicles)?

Are there any independent witness’ to the accident?