Sunday, 05 September 2010
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Motor Vehicle Claim Form

Please click here to read important information on your Motor Vehicle Claim


 

1. Policyholder

2. Insured Vehicle

3. Driver (Please complete these details in respect of the person in charge of the vehicle at the time of the Incident)

Was the vehicle being used with the full knowledge and consent of the policyholder?

Have you (the Policyholder) or the driver of the vehicle at the time of the Incident:

If “Yes”, to (i), (ii) or (iii), please give details below:

4. Incident Date

5. Details of Incident

Was the street wet?
Did the other party admit liability?
Are you claiming for damage to your vehicle?
Was the vehicle Towed?

Please download the diagram below, make the necessary markings, then please upload in the area below


Motor Claim Form Diagram (PDF 330KB)


 

Did the driver suffer any injury?
If Yes, was medical attention required?
Was the vehicle towed from scene of accident?
Did you authorise this towing?

6. Police

Did the Police attend the Incident?

If Yes, please state:

If an Accident, Did the Police indicate which driver was at fault?

If Yes, please state:

7. Other Parties (Please complete this section if any other vehicles or property involved)

8. Witnesses

Passengers in Insured Vehicle

Independent Witnesses

Declaration


The information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld. I authorise my Insurer to undertake on my behalf whatever actions are necessary to indemnify me within the terms of my policy including if necessary, removal of my vehicle to alternative premises to enable repairs to be carried out by a qualified Motor Body Repairer. I understand that this claim may be refused if information is untrue, inaccurate or concealed.


I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify YOURCOY in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.

I/We agree:

Type the characters you see in the picture below