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Insured Details
Policyholder / Named Insured
First Name
(Required)
Last Name
(Required)
Insured's Address
(Required)
Street Address
City
State
Postcode
Email Address
(Required)
Mobile Phone
(Required)
Policy Number
(Required)
Insured Person Name or Business Name
GST Registered?
(Required)
Yes
No
Unsure
Is the Insured the preferred contact person?
Yes
No
Please list details
Name
(Required)
First
Last
Email Address
(Required)
Mobile Phone
(Required)
Claim Details
Date of Loss / Incident
(Required)
Day
Month
Year
Time of Loss
Hours
:
Minutes
AM
PM
AM/PM
Loss Location
Driver Name
(Required)
Driver Date of Birth
Day
Month
Year
Vehicle Registration Number
(Required)
Drivers Licence Number
(Required)
Drivers Licence Expiry
Day
Month
Year
How long have you held your driver's licence (for the class of vehicle involved in this claim)?
(Required)
Select one...
Less than 1 year
1 year
2 year
3 year
4 year
5 year
6 year
More than 6 years
Vehicle Type
(Required)
Sedan
Hatchback
Wagon
SUV / 4WD
Utility (Ute)
Van
Motorcycle / Scooter
Light Truck (under 4.5T GVM)
Heavy Truck (over 4.5T GVM)
Bus / Minibus
Trailer
Caravan / Camper Trailer
Boat / Personal Watercraft
Construction / Earthmoving Equipment
Other
Licence Class
C (Car)
R / RE (Motorcycle)
LR (Light Rigid)
MR (Medium Rigid)
HR (Heavy Rigid)
HC (Heavy Combination)
MC (Multi Combination)
Learner / P1 / P2
Other
Loss / Incident Details
Was there a third party involved?
(Required)
Yes
No
Description of claim
(Required)
Is there damage to the insured vehicle?
(Required)
Yes, the vehicle is damaged
No damage to the insured vehicle
Supporting Documents / Files
Click here to upload files to substantiate your claim eg. police report, images, quotes, invoices, photos etc.
File Upload 1
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 8 MB.
File Upload 2
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 8 MB.
File Upload 3
Accepted file types: jpg, jpeg, png, gif, pdf, doc, docx, Max. file size: 8 MB.
Do you have additional files to upload?
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No
File
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Select files
Max. file size: 8 MB.
Disclosure Questions
Please answer if applicable to claim
Did the driver consume any alcohol or drugs during the 12 hours before the accident?
(Required)
Yes
No
Was the driver tested by the police for alcohol or drugs?
(Required)
Yes
No
In the past 5 years has the driver:
a. Been charged with, or convicted of, or penalised by a traffic infringement (includes on the spot fines but does not include parking offences)?
(Required)
Yes
No
b. Had a driving licence suspended, cancelled or refused by any authority?
(Required)
Yes
No
c. Been charged with or convicted of any criminal offence?
(Required)
Yes
No
d. Had any insurance policy cancellation or special conditions imposed?
(Required)
Yes
No
If you answered yes to any of the above, please provide details
Additional comments
Signature
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