NSURE Motor Vehicle Claim Form

MOTOR VEHICLE CLAIM FORM

If any questions, please contact us at 1300 067873
AT THE SCENE OF THE ACCIDENT:

1. DO NOT ADMIT LIABILITY.

2. Comply with Police reporting requirements.

3. If another vehicle is involved, obtain:

(i) The owner's name, address and telephone number.

(ii) The driver's name and address.
(iii) The name of the owner's insurance company.

(iv) The make, type and registration number of the vehicle.

(v) The name and address of any witnesses.

4. Record the date, time and location of the collision.
1. Policyholder
Name and Address of Policyholder
Phone Number

Area Code Phone Number
Best time to call

: Hour Minutes AM/PM Option
Insurer
Policy No.
Expiry Date
For what purpose was the vehicle being used?
Email address of the person completing the form *
example@example.com
Contact number of the person completing the form *

2. Insured Vehicle
Make & Model
Body Type
Year of Manufacture
Registration No.
Expiry Date of Registration
Name & Address of Finance Co. (if applicable)
Have there been any engine, body or transmission modifications from the manufacturer's original specifications or any accessories added?
If yes, please give details.

3. Driver

(Please complete these details in respect of the person in charge of the vehicle at the time of the accident)
Full Name and Address of Driver *
Gender
Date of Birth

Day Month Year
Driver's Licence No.
State of Issue
How long has the driver held a driver's licence?
Expiry Date of Licence
Was the vehicle being used with the full knowledge and consent of the policyholder?
What's the relationship of the Driver to the Policyholder?
Have you (the Policyholder) or the driver of the vehicle at the time of the accident:
(i) been involved in any previous motor vehicle accident in the last 5 years?
(ii) been charged with any offence in relation to the use of a motor vehicle in the last 5 years?
(iii) had any insurance declined or cancelled, been refused renewal of an insurance or had special terms imposed in the last 5 years?
If "Yes" to (i), (ii) or (iii), please give details below:
Was the driver under the influence of any drug or alcohol at the time of the accident?
If yes, please state what drugs or how much alcohol was consumed by the driver in the 12 hours prior to the accident:
Did the driver undergo a breath test?
If yes, what was the reading?
Has the driver's motor vehicle licence ever been cancelled or suspended?
If yes, please give details:

4. Accident Date
Date of accident

Day Month Year
Time of accident

: Hour Minutes AM/PM Option

5. Description of Accident
Name of street where accident occurred
If at an intersection, names of intersecting streets
Suburb, Town, City
State clearly and fully how the accident occured
Was the street wet?
Did the other party admit liability?
If yes, please give details:
Please describe the position of all the vehicles and pedestrians at the time of the accident
Did the driver suffer any injury?
If yes, was medical attention required?
If yes, state name and address of doctor or hospital
Please indicate INSURED vehicle's speed immediately prior to accident
Please indicate OTHER vehicle's speed immediately prior to accident
Was the vehicle towed from scene of accident?
If yes, please give name of towing contractor
Did you authorise this towing?
Where can the vehicle be inspected?
Estimated Cost of Repairs
(including parts)
Repair Quotation Number
Please upload photos of the incident and damage to the vehicles

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6. Police
Did the police attend the accident?
Date reported to police

Day Month Year
Time reported to police

: Hour Minutes AM/PM Option
If yes, from which police station?
Name of police officer
Did the police indicate which driver was at fault?
If yes, name of driver charged or cautioned
Nature of charge or caution
7. Other Parties

(Please complete this section if any other vehicles or property involved)
Number of other vehicles involved
Owner's name and address
Phone Number

Area Code Phone Number
Make and Model of Vehicle
Registration Number
Driver's name and address
Licence Number
Please give particulars of damage to other party's vehicle and/or property
8. Witnesses
Passengers in Insured Vehicle
Independent Witnesses
Please upload a diagram of the accident*

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9. ABN Details
Are you a registered business?
ABN Number
What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?
10. 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 Nsure General Insurance Advisors 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".
Driver's Signature

Clear
Date

Day Month Year
Do you agree to us sending your information to our claims partners to assist in the prompt settlement of your claim? *

Yes No
File Upload

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Should be Empty:

MOTOR VEHICLE CLAIM FORM

1. Policyholder

2. Insured Vehicle

3. Driver

4. Accident Date

5. Description of Accident

6. Police

7. Other Parties

8. Witnesses

9. ABN Details

10. Declaration