MOTOR VEHICLE CLAIM FORM

Date:	Date Lodged:
Contact Name:	Claim No:
Phone:	Claim Manager:
Mobile:	Phone No:
Email:	Email:
Assessor Details:

Insured:
Underwriter:	Excess:
Policy Type:	Policy No:
Registered for GST: Yes / No	ITC Entitlement: %
ABN:

Vehicle:
Rego No:	Vehicle Finance:
Drivers Name:	Drivers Contact No:
Drivers D.O.B.:	Relationship to Insd:
Drivers Lic. No:	Class:
Years held Lic:	Expiry Date:
In the past 5 years has the policy holder or driver (Allianz Policies Only):
Had a driver’s licence cancelled, suspended, been disqualified, from driving or committed any driving related alcohol or drug offence? Yes / No
Had an insurance policy declined, cancelled or conditions imposed on an insurance policy? Yes / No
Committed any criminal offences? Yes / No
If YES please provide details:

Date of the Incident: / /	Time: am|pm
Incident Location:
State: Postcode:
How did the Accident happen:
Speed travelling at impact: km/h
Were the police called: YES | NO	24hrs prior to accident did the driver consume:
Incident No:	Alcohol: YES | NO
Police Station:	Drugs: YES | NO
Officers Name:	Was the driver breathalysed: YES | NO
Road Conditions: SEALED |UNSEALED	OTHER :
Weather Conditions: DRY | RAINING| FOGGY|OTHER:

Third Party Details:
Drivers Name:	Licence Number:
Phone number:	Address:
Year, Make and Model of Vehicle:
Registration No:	Colour of Vehicle:
Insurance Company:
Where is the damage to the third party vehicle:
Other:

Insured Vehicle details for repairs
Is there damage to the insured vehicle: Yes / No	Is the vehicle still driveable: Yes / No
Tow Truck Required: Yes / No PD / UNPD	Tow Truck Company Details:
Where is the damage to the vehicle:
FRONT | REAR |DRIVER’S SIDE | PASSENGER SIDE | ROOF | UNDERCARRIAGE |
Other details:
Where is the Vehicle now:
Have quote and images been obtained: Yes / No Amount: $
If no, when will you be getting quote:
Preferred repairer’s details:

Diagram | Other details: