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  • 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

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  • 2. Insured Vehicle

  • 3. Driver

    (Please complete these details in respect of the person in charge of the vehicle at the time of the accident)
  • Have you (the Policyholder) or the driver of the vehicle at the time of the accident:
  • 4. Accident Date

  •  :
  • 5. Description of Accident

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  • 6. Police

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  • 7. Other Parties

    (Please complete this section if any other vehicles or property involved)
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  • 8. Witnesses

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  • 9. ABN Details

  • 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".

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