Non 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 just had. 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	Mr. Mrs. Miss. Ms.
First Name
Last Name
Address
Post Code
Home Phone
Work Phone
Mobile
Email
DOB
Are you the Owner?	Please Select Yes No

PERSON AT FAULT
Title	Mr. Mrs. Miss. Ms.
First Name
Last Name
Address
Post Code
Home Phone
Work Phone
Mobile
License No.
Is this person the Owner?	Please Select Yes No

VEHICLE OWNER
Title	Mr. Mrs. Miss. Ms.
First Name
Last Name
Address
Suburb
Home Phone
Work Phone
Mobile

OTHER VEHICLE OWNER
Title	Mr. Mrs. Miss. Ms.
First Name
Last Name
Address
Suburb
Home Phone
Work Phone
Mobile

VEHICLE DETAILS
Vehicle Rego No
Business/Private Use
Make
Model
Year of Car

OTHER VEHICLE DETAILS
Vehicle Rego No.
Make
Model
Year of Car

INSURANCE DETAILS
Insurance Co.	Insurance Company AAMI NRMA GIO JUSTCAR CGU SUNCORP ZURICH ALLIANZ QBE LUMLEYS OTHER PLEASE SPECIFY
Please Enter your Insurance Company name
Type of Cover	Select Type Of Cover Third Party Comprehensive CTP
Claim No.
Are you claiming on your policy or direct against the other parties?	Select Claim Type Own Policy Other Party

OTHER INSURANCE DETAILS
Insurance Co.	Insurance Company AAMI NRMA GIO JUSTCAR CGU SUNCORP ZURICH ALLIANZ QBE LUMLEYS OTHER PLEASE SPECIFY
Please Enter your Insurance Company name
Type of Cover	Select Type Of Cover Third Party Comprehensive CTP
Claim No.

ACCIDENT DETAILS
Accident Details:
Date	February 2012   M T W T F S S 6 30 31 1 2 3 4 5 7 6 7 8 9 10 11 12 8 13 14 15 16 17 18 19 9 20 21 22 23 24 25 26 10 27 28 29 1 2 3 4 11 5 6 7 8 9 10 11
Time
Street
Suburb
No of Cars Involved
Who Admitted Liability?	Other Person Nobody
Was it Verbally of Written?	Verbally Written
Were there any witnesses?	No Yes
If so please provide information

OTHER INFORMATION
Location of Damage
Is you car Driveable?	Yes No
Date Rental Vehicle Required	February 2012   M T W T F S S 6 30 31 1 2 3 4 5 7 6 7 8 9 10 11 12 8 13 14 15 16 17 18 19 9 20 21 22 23 24 25 26 10 27 28 29 1 2 3 4 11 5 6 7 8 9 10 11
Which repairer are you using
Est days to repair
Are you registered for GST?	No Yes
ABN Number
Did Police Attend scene?	No Yes

POLICE INFORMATION
Police Station
Officer Name
Officer Number
Telephone Number
Police information
Was anyone Booked?
On what charges?
Police Event Number (this starts with E)

How did you Here about us?	Google Repairer Previous Customer Friends and Family Other Please Specify:
Other:
Additional Information
	Disclaimer: I understand and authorise that any data collected may be used to facilitate my claim.

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