Tuesday, 07 February 2012
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Motor Vehicle Claim Form

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

  2. 1. Policyholder

  3. Full Name and Address of Policyholder
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  4. Occupation
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  5. Email address(*)
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  6. Telephone Home
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  7. Telephone Business
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  8. Insurer
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  9. Policy Number
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  10. Expiry Date
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  11. For what purpose was the vehicle being used?
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  12. GST Details: Are you registered for GST Purposes?
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  13. ABN No
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  14. To what extent are you entitled to claim an Input Tax Credit for this policy? (%)
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  1. 2. Insured Vehicle

  2. Make & Model
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  3. Body Type
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  4. Year of Manufacture
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  5. Registration No
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  6. Engine No
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  7. V.I.N. No
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  8. Expiry Date of Registration:
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  9. Name & Address of Finance Co. if applicable
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  10. Have there been any engine, body or transmission modifications from the manufacturer’s original specifications or any accessories added?
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  11. If yes, please give details:
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  12.  

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

  2. Full Name and Address of Driver
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  3. Occupation
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  4. Sex
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  5. Date of Birth
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  6. Drivers Licence No
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  7. State of issue
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  8. How long has the driver held a motor vehicle drivers licence? (years)
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  9. V.I.N. No
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  10. Expiry Date of Licence
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  11. Was the vehicle being used with the full knowledge and consent of the policyholder?
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  12. What is the relationship of the Driver to the Policyholder?
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  13. If Other, please describe
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  14. Have you (the Policyholder) or the driver of the vehicle at the time of the Incident:

  15. (i) been involved in any previous motor vehicle accident in the last 5 years?
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  16. (ii) been charged with any offence in relation to the use of a motor vehicle in the last 5 years?
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  17. (iii) had any insurance declined or cancelled, been refused renewal of an insurance or had special terms imposed in the last 5 yrs?
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  18. If “Yes”, to (i), (ii) or (iii), please give details below:

  19. Name
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  20. Date
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  21. Particulars (eg, name of insurance company, details of charges etc)
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  22. Name
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  23. Date
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  24. Particulars (eg, name of insurance company, details of charges etc)
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  25. Name
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  26. Date
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  27. Particulars (eg, name of insurance company, details of charges etc)
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  28. Was the driver under the influence of any drug or alcohol at the time of the accident?
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  29. Please state what drugs or how much alcohol was consumed by the driver in the 12 hours prior to the accident
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  30. Did the driver undergo a breath test?
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  31. If Yes, what was the reading?
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  32. Has the driver’s motor vehicle licence ever been cancelled or suspended?
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  33. If Yes, please give details:
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  34.  

  1. 4. Incident Date

  2. Date of Incident
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  3. Time of Incident (am/pm)
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  4. 5. Details of Incident

  5. Name of street where Incident occurred
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  6. If at an intersection, names of intersecting streets
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  7. Suburb, Town, City
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  8. State clearly and fully how the Incident occurred (space for 1000 words)
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  9. Was the street wet?
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  10. Did the other party admit liability?
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  11. If Yes, please give details:
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  12. Who do you believe is at fault?
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  13. Are you claiming for damage to your vehicle?
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  14. Was the vehicle Towed?
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  15. Where is the Vehicle now?
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  16. Please download the diagram below, make the necessary markings, then please upload in the area below

    Motor Claim Form Diagram (PDF 330KB)

  17. Upload Motor Claim Diagram
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  18.  
  1. Did the driver suffer any injury?
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  2. If Yes, was medical attention required?
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  3. If Yes, state name and address of doctor or hospital
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  4. Please indicate Insured Vehicle’s speed immediately prior to accident
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  5. Please indicate Other Vehicle’s speed immediately prior to accident
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  6. Was the vehicle towed from scene of accident?
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  7. If Yes, please give name of towing contractor
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  8. If Yes, please give name of towing contractor
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  9. If Yes, state name and address of doctor or hospital
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  10. Where can the vehicle be inspected? (If at a repairer’s premises - name & address of repairer)
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  11. Repairers Phone
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  12. Estimated Cost of Repairs (including parts) $
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  13. Repair Quotation No
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  14. 6. Police

  15. Date reported to Police
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  16. Time reported to Police (am/pm)
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  17. Did the Police attend the Incident?
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  18. Where can the vehicle be inspected? (If at a repairer’s premises - name & address of repairer)
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  19. If Yes, please state:

  20. (i) From which Police Station?
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  21. (ii) Police Event Number
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  22. If an Accident, Did the Police indicate which driver was at fault?
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  23. (iii) Name of Officer
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  24. If Yes, please state:

  25. (i) Name of driver charged or cautioned
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  26. (ii) Nature of charge or caution
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  1. 7. Other Parties (Please complete this section if any other vehicles or property involved)

  2. Number of other vehicles involved
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  3. Owners Name
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  4. Owners Address & Postcode
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  5. Owners Phone Number
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  6. License Number
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  7. Make and Model of Vehicle
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  8. Age (years)
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  9. Drivers Name
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  10. Drivers Address & Postcode
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  11. Drivers Phone Number
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  12. Please give particulars of damage to other party’s vehicle and/or property
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  13. If an Accident, Did the Police indicate which driver was at fault?
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  14. 8. Witnesses

  15. Passengers in Insured Vehicle

  16. Passenger 1 Name and Address
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  17. Passenger 2 Name and Address
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  18. Passenger 3 Name and Address
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  19. Independent Witnesses

  20. Witness 1 Name and Address
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  21. Witness 2 Name and Address
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  22. Witness 3 Name and Address
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  1. 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”.

  2. I/We agree with the above statement(*)
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