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Motor Vehicle Claim Form

1. Policyholder

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2. Insured Vehicle

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

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

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

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4. Incident Date

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5. Details of Incident

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

Motor Claim Form Diagram (PDF 76KB)

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6. Police

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If Yes, please state:

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If Yes, please state:

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

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8. Witnesses

Passengers in Insured Vehicle

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Independent Witnesses

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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”.

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