Please select the the type of policy that you wish to make a claim against Personal Insurance Business Insurance Please select the claim type * - Select - Property Claim Form Motor Vehicle Claim Insured Name Policy Number Contact Phone Email Registered for GST Yes No ABN Input Tax Credit entitlement on premium % Input Tax Credit entitlement on property damaged % When did the loss, theft or damage occur? Date Time Address Which is Occupied by insured who Unoccupied / Vacant A holiday home Please describe what happened * Any loss involving malicious damage, lost or stolen property must be reported to the police Were the premises occurpied at time of loss? Yes No If no, date last occupied Do you know who is responsible for the loss, theft or damage? Yes No Name Address Please detail what has been lost/stolen/damaged and estimate value to repair/replace Particulars Amount Claimed Fusion/Power Surge Claims Age of Motor Is the motor under warranty? Yes No Burglary Claim How was the building entered? Available security to premises Give details of any security improvements taken since the loss Police Station Report No. Date Reported Reporting Officer If your insurer approves a cash settlement, would you like funds deposited into your bank account? Yes No Bank BSB Account Name Account No. History Had insurance declined, cancelled or special conditions imposed in the last 5 years? Yes No Convicted of or had any fines or penalties imposed for any criminal offence? Yes No Had an accident or made a claim on a motor insurance policy in the last 5 years? Yes No If YES to any of the above, please provide details Was the vehicle being used for Business use Private use Vehicle Details Year Make Rego Model Is there any finance owing on the vehicle? Yes No Are you claiming damage for the vehicle? Yes No Detailed description of the damage Was the vehicle towed? Yes No Has a repair quote been obtained? Yes No What is the current location of the vehicle? Preferred repairer details Incident Details Date Time Location (street/suburb) Please describe what happened in the accident and why it occurred e.g. speed, traffic lights, weather Who does the driver consider is at fault and why? Driver Details Name Contact Phone Date of Birth License No. Expiry Date Year Licensed License Type Learners Probationary Full Class Did the driver consume alcohol/drugs/medication in the 12 hours prior to the accident? Yes No Had insurance declined, cancelled or special conditions imposed in the last 5 years? Yes No Convicted of or had any fines or penalties imposed for any criminal offence? Yes No Had an accident or made a claim on a motor insurance policy in the last 5 years? Yes No If YES to any of the above, please provide details Third Party Details Please note: Driver's full name, contact number, residential address, registraion, and license number is required for not at fault accidents. Name Contact Phone Address Insurance Company Policy/Claim No. Rego License No. Year Make Model Detailed description of the damage Police Details (Name/Station/Police Report No.) Witness Details Additional Information Declaration Do you agree to the declarations? I agree By submission of this claim for, you acknowledge and accept the following Declarations Privacy The Privacy Act and the Australian Privacy Principles require your insurer to tell you that they collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to Insurance Reference Services (IRS), etc. or other parties as required by law. By reading and acknowledging the Adroit privacy collection notice you consent for us to proceed with submitting this information to your insurer. You have to right to seek access to your personal information and to correct it at any time. Please contact us on (03) 5244 7813, 8:45am - 5:15pm, Mon-Fri and advise the changes. Declaration I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the privacy information of all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then the Insurer will be unable to process my/our claim.