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First name
*
Last name
*
Phone
*
Email
*
Postal Address
Driver Name
*
Date of Birth
*
Driving Licence #
*
Licence Expiry Date
*
Which groups of vehicle is the driver licensed to operate?
*
How long has the driver held this licence?
Is the driver's licence provisional?
*
Does the driver have any previous motoring convictions? If yes please state date. Write "None" if this is not applicable.
Does the driver have any issues with vision or physical impairment? Please describe if applicable?
Was the vehicle being driven with the owner's knowledge?
*
Yes
No
Driver's relation to the vehicle owner
*
Has the driver ever had any insurance claim or policy refused or declined? Please provide details below.
*
Was the driver under the influence of of drugs, alcohol, or any other intoxicating substances?
*
Yes
No
Registration # of the vehicle
*
Year Model
*
Make & Model
*
Colour of Body
*
Engine #
*
Chassis #
*
Current market value
Vehicle body type
Mileage
Transmission Type
Automatic
Manual
Please upload a photo of the registration certificate or window sticker.
*
Upload File
Please upload a photo of the ACCF certificate
Upload File
If the vehicle is subject to finance agreement please state the financiers name.
Please describe the purpose that this vehicle was being used for.
*
Please describe in your own words details of the damage.
What is the estimated cost to repair?
Location of vehicle for inspection:
*
Do you have a preferred repairer?
In the case of commercial vehicles, please state the nature of goods carried, if applicable:
If commercial, what quantity of load was being carried?
If commercial carry, who owns the goods?
If commercial, was any trailer attached?
Did the Police attend the accident site?
Yes
No
Upload a copy of the Police Report
Upload File
If no, have they been informed?
Yes
No
Has the driver received a traffic infringement notice, fine, or legal notice on this matter?
Yes
No
If another vehicle was involved, please provide it's owners name
What is the other owner's phone contact?
What is the vehicle registration # of the other vehicle?
What is the damage to this vehicle?
If the other vehicle is insured, please provide the insurer name and policy #:
If there were injured persons in your vehicle as result of the accident, please provide their names, age, and describe their injuries below:
If there were injured persons in the other vehicle as result of the accident, please provide their names, age, and describe their injuries below:
Date and time of the accident
*
Month
Month
Day
Year
Time
:
Hours
Minutes
AM
Where did the accident happen? Please give a location
*
Describe the accident - a detailed description will assist the insurer in understanding what happened
*
Photo # 1 of Damage
Upload File
Photo # 2 of Damage
Upload File
Please provide the names and contact details of any witnesses
In case of theft, what precautions are in place to prevent a loss?
Is there any information you may have that will help identify the culprit?
Please list the items stolen
Are the stolen items also insured elsewhere?
Please upload a sketch of the accident. Details such as positions of the vehicle and directions before the incident would be very helpful.
*
Upload File
Please upload repair quote # 1
Upload File
Please upload repair quote # 2
Upload File
Date of lodgement
*
Month
Month
Day
Year
Signature
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