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Motor Insurance Claim Form
Your Details
Driver details
Loss details
Reported date
Policy number
First name
Last name
Street address
Suburb
State
-- Select an answer --
NSW
QLD
SA
TAS
VIC
WA
ACT
NT
Postcode
Phone number
Email address
GST registered
Yes
No
Are the driver details the same as the insured details?
Yes
No
Date of birth
Driving experience
License suspension or cancellation
Date of loss
Time of loss
Vehicle registration
Type of loss
Single vehicle
Multiple vehicle
Theft
Hail
Windscreen / Glass
Fire
Malicious damage
Natural events
Liability
Hire / Loan car accident
Other
Description of loss / Objects damaged
Total Loss?
Yes
No
Please provide photos of the Vehicle Damage below:
Location of loss
Previous damage (if any)
Is the vehicle safe to drive?
Yes
No
Was a tow required?
Yes
No
Please provide the name of the towing company and vehicle location
Witness Details (if any)
First name
Last name
Phone number
Street address
Suburb
State
Postcode
Is there anything else that you would like to tell us?
Email address
