Motor Vehicle Insurance Claim - Insurance Broker Melbourne

Motor Vehicle Claim Notification Form

Policy Number

Client Ref No.

Insured

Insured’s Name

Address

Street Address Address Line 2 City State / Province / Region Postcode Country

Email*

Phone

Are you registered for GST?*

Yes
No

What is your Australian Business Number (ABN)?

To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?

Are you the sole owner of the insured vehicle?*

Yes
No

If NO, who is the owner?

Insured Vehicle

Make & Model

Year

Rego Number

Rego Expiry Date

Colour

Damage Summary

Trailer Details (if applicable)

Make

Type

Year

Registration No.

Driver

Surname

Given Name(s)

Address

Postcode

Phone No.

Date of Birth

Driver Licence

Expiry Date

Years Held

Gender*

Male
Female

Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years*

Yes
No

If Yes, please give details including dates and circumstances.

Did you consume any alcohol or take drugs during the 12 hours prior to the accident?*

Yes
No

If Yes, what was consumed, in what quantities and when consumed.

Did you undergo a breath test or blood test for alcohol or drugs?*

Yes
No

If Yes, what was the result.

Did you refuse to undergo any of the above tests?*

Yes
No

Damage to Insured Vehicles

Was your vehicle damaged?*

Yes
No

Was your vehicle towed away?*

Yes
No

Have you obtained a repair quote?*

Yes
No

Repair quote amount $

(Attach Quote)

File

Max. file size: 2 MB.

If you are unable to attach a quote, please advise the name of the repairer, their contact details and quote number

Name of repairer

Contact details

Quote number

If not driveable, what is the full address where the vehicle can be inspected?

Phone No.

Describe in detail where the damages appear on your vehicle.

Accident Details

At the time of the accident was the vehicle being used for business or private use?*

Business
Private

Date of accident

Time of accident

What was the accident location?

Street

Suburb

P/Code

How did the accident happen?

Who do you consider was at fault?*

Myself
Other Driver
Something Else

Describe what / who else was at fault

Estimated speed of YOUR vehicle just before the accident

Estimated speed of OTHER vehicle just before the accident

What was the condition of the road?

Sealed
Unsealed
Smooth
Rough
Wet
Dry

How was visibility?*

Good
Moderate
Poor

Were there any witnesses to the accident?

Yes
No

If yes, please provide name/s, address/s and phone number/s.

Did Police attend the accident?*

Yes
No

Police Station

Name/Number of Officer

If No, state time and date reported to Police

Did Police indicate who was responsible?

Yes
No

If Yes, Name of Driver

Did Police charge either driver or suggest action may be taken?

Yes
No
Charge

Damage to Other Vehicle or Property

Vehicle or Property No. 1

Name of other driver:

Age:

Phone

Licence No:

Vehicle Make & Model:

Rego No:

Name of Registered Owner:

Address:

Phone

The Other Insurance Company:

Policy Number:

Description of Damage

Vehicle or Property No. 2

Name of other driver:

Age:

Phone

Licence No:

Vehicle Make & Model:

Rego No:

Name of Registered Owner:

Address:

Phone

The Other Insurance Company:

Policy Number:

Description of Damage

Personal Injuries

Was anyone injured in the accident?

Yes
No

Person A

Name

Type of Injury

Injured Party (Passenger/Driver)

Vehicle (Registration No.)

Person B

Name

Type of Injury

Injured Party (Passenger/Driver)

Vehicle (Registration No.)

Privacy

The Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.

Internal Dispute Resolution (IDR) Statement

Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).

Declaration

1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.

Name of Driver

Date

Name of Insured

Date

How To Make A Motor Vehicle Claim

Whether at fault or not and to avoid delay, it is easier to claim on your Insurer and let them recover for you. Here are the steps to be taken: -
1. Obtain a quotation from a reputable repairer.
2. The repairer will usually arrange the assessment and for this you must: -
a) Compete a claim form,
b) Supply a copy of your licence to be left with the claim form at the repairers.
3. On the day of the assessment (to be pre-arranged with you), the vehicle should be left all day with your repairer, repairs should be authorised on that day and work can commence. You will pay your excess to the repairer when collecting the repaired vehicle.
If you are not at fault: -
•Your excess is recoverable
•Car hire may be paid for, if a business registered vehicle, but not necessarily all costs. Please note, the refund of excess and car hire is paid by the third party or their Insurer and thi9s usually takes between 3-6 months. If not refund received after 6 months, you can: -
•Follow this up yourself by contacting your Insurer
•Contact our office and ask our assistance.
4. In the event of a total loss, the market value will be determined by the assessor. At times you may not agree on this figure, however, it is your prerogative to obtain another valuation. We can advise.
5. If the vehicle has been stolen, your Insurer will apply for a Police report. They will generally wait for 4-6 weeks before settling the claim in the event the vehicle is recovered (80% usually are recovered albeit not in the condition when last seen by the owner).
6. If your vehicle is not damaged or damage is minor but you have caused damage to an third party and the accident is your fault, a claim form must be completed and sent to our office with a copy of your licence and excess if applicable, and then forward any letters of demand with quotations.

Please provide bank details in order for your claim payment to be settled via EFT.

BSB Number:

Bank Account Number:

Name of Bank:

Account Holder Name

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