For Comprehensive and Third Party Property Damage Policies

SECTION 1 - POLICYHOLDER DETAILS

Policyholder Name *

Policy Number

Date of Birth *

Residential Address *

Street AddressStreet Address line 2

City

State

Postcode

Phone Number *

Email Address *

Are you the Policyholder? *

YesNo

If no, state your name and relationship *

SECTION 2 - VEHICLE DETAILS

Make *

Model *

Year *

Registration Number *

Is the vehicle financed? *

YesNo

Financer Name *

Loan Account Number *

Proof of Ownership Provided? *

YesNo

SECTION 3 - DRIVER DETAILS (AT TIME OF INCIDENT)

Driver Name *

Driver Date of Birth *

Relationship to Policyholder *

Driver's Licence Number

State of Issue

At the time of the incident, was the driver under the influence of alcohol/drugs? *

YesNo

SECTION 4 - INCIDENT DETAILS

Date of Incident *

Time of Incident

Exact Location of Incident *

Describe what happened (full narrative) *

Was the vehicle drivable after the incident? *

YesNo

Was Towing required? *

YesNo

Was the vehicle stolen or vandalised? *

YesNo

Was the vehicle being used for business, rideshare, delivery, or any excluded purpose? *

YesNo

Was the vehicle locked and were keys secured? (Theft claims) *

YesNoN/A

Was a Third Party or multiple Third Parties involved? *

YesNo

How many Third Parties were involved?

Third Party Driver (1)

Name of Driver (Third Party Driver 1)

Phone Number (Third Party Driver 1)

Address (Third Party Driver 1)

Vehicle Registration (Third Party Driver 1)

Vehicle Make/Model (Third Party Driver 1)

Insurance Company (Third Party Driver 1)

Policy Number (Third Party Driver 1)

Third Party Driver (2)

Name of Driver (Third Party Driver 2)

Phone Number (Third Party Driver 2)

Address (Third Party Driver 2)

Vehicle Registration (Third Party Driver 2)

Vehicle Make/Model (Third Party Driver 2)

Insurance Company (Third Party Driver 2)

Policy Number (Third Party Driver 2)

Third Party Driver (3)

Name of Driver (Third Party Driver 3)

Phone Number (Third Party Driver 3)

Address (Third Party Driver 3)

Vehicle Registration (Third Party Driver 3)

Vehicle Make/Model (Third Party Driver 3)

Insurance Company (Third Party Driver 3)

Policy Number (Third Party Driver 3)

Third Party Driver (4)

Name of Driver (Third Party Driver 4)

Phone Number (Third Party Driver 4)

Address (Third Party Driver 4)

Vehicle Registration (Third Party Driver 4)

Vehicle Make/Model (Third Party Driver 4)

Insurance Company (Third Party Driver 4)

Policy Number (Third Party Driver 4)

Any witnesses? *

YesNo

How many witnesses?

Name (Witness 1)

Phone (Witness 1)

Name (Witness 2)

Phone (Witness 2)

Name (Witness 3)

Phone (Witness 3)

Name (Witness 4)

Phone (Witness 4)

SECTION 5 - DAMAGE DETAILS

Describe the damage to your vehicle *

Photos Provided *

YesNo

Dashcam Footage Available *

YesNo

Current Location of Vehicle *

Location Details

SECTION 6 - HIRE CAR DETAILS

Was a Hire Car used? *

YesNo

Hire Car Provider Name *

Hire Car Provider Email Address

Dates of Hire

Receipts Attached *

YesNo

SECTION 7 - CAR CONTENTS CLAIM

Are you claiming for Car Contents?

YesNo

List of items lost/damaged (max $2,000)

Proof of ownership provided? *

YesNoN/A

Police Incident Number (for theft)

Was the vehicle locked at the time? *

YesNoN/A

SECTION 8 - WINDSCREEN CLAIM

Are you claiming for Windscreen Damage? *

YesNo

Type of Damage *

RepairReplacementN/A

Photos Provided *

YesNoN/A

SECTION 9 - SUPPORTING DOCUMENTS CHECKLIST

Upload Supporting Documents

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Upload all supporting documents here (photos, reports, receipts, etc.).

SECTION 10 - PRIVACY & DECLARATION

Privacy Notice

We collect your personal information to assess and manage your claim. Your information may be shared with insurers, repairers, assessors, and service providers as required. Our privacy policy is available here.

Privacy Declaration *

Declaration

I declare that the information provided in this claim form is true and correct. I understand that providing false or misleading information may result in denial of my claim.

I agree. *

Signature *

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Your Name *

Date *

Please complete the verification below. *

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