At Fault Accident Replacement Vehicle - Claim Form

It is important for you to try and fill this form out to the best of your ability in relation to the accident you have had so we can claim the money back off your insurance company. We realise this may be a stressful time and if you prefer to speak to one of our specialists please call them on 1300 135 485.

Filling this form in should take no longer than 5 minutes provided you have all the information handy. Once we have these details we should be able to facilitate a vehicle to you a lot quicker. If you don’t have everything, don’t worry, just fill in what you can. Remember to call if you have any questions.

YOUR DETAILS
Title
First Name
Last Name
Address
Post Code
Home Phone
Work Phone
Mobile
Email
DOB
Are you the Owner?

INSURANCE DETAILS
Insurance Co.
Please Enter your Insurance Company name
Type of Cover
Claim No.

OTHER INFORMATION
Date Rental Vehicle Required
Which repairer are you using
Est days to repair
Entitlement rate for hire car.
Number of Days you are entitled to a hire car
How did you Here about us?
Other:
Additional Information
Disclaimer: I understand and authorise that any data collected may be used to facilitate my claim.