Motor Claim

Motor Claim Form

Motor Claim

Policy Holder Details

Insured Vehicle

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

Date of Birth
MM slash DD slash YYYY

License Details

Expiry Date of Driver License
MM slash DD slash YYYY
Driver License Type

Driver History (Have you (the policyholder) or the driver of the vehicle at the time of the accident)

Driver Condition

Accident Details

Date of accident
MM slash DD slash YYYY
Max. file size: 512 MB.

Repairer

Max. file size: 512 MB.

Police Details

Third Party Involvement (If yes, please complete below)

Declaration

Important: 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 [Value not set] 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?
Date
MM slash DD slash YYYY

Confused? Don’t worry, that’s what we’re here for.
Call us on 1800 958 384

Our contact details:

Phone: +61 2 9959 2900
Fax: +61 2 9959 2999
Email: [email protected]

Our contact details:

Phone: +61 2 9959 2900
Fax: +61 2 9959 2999
Email: [email protected]