Car Insurance Claim Form

Car Insurance Claim Form

Car Insurance Claim Form THIS FORM IS TO BE COMPLETED IF YOUR MOTOR VEHICLE HAS BEEN INVOLVED IN AN INCIDENT. THE COMPLETION AND LODGEMENT OF THIS FORM IS NOT AUTOMATIC ACCEPTANCE OF YOUR CLAIM. ONCE THIS FORM HAS BEEN RECEIVED BY US, WE WILL CONTACT YOU. OFFICER USE ONLY Claim Number PLEASE PRINT IN BLOCK LETTERS and answer all questions where applicable (provide full and complete answers). If a particular question does not apply, please write "Nil" in the space provided. Claim Officer If the space provided below is insufficient to provide all the details, please attach a separate sheet. THE FORM SHOULD BE COMPLETED AND RETURNED TO BUZZ INSURANCE WITHIN 7 DAYS OF RECEIPT BY THE INSURED. NO REPAIRS SHOULD BE CARRIED OUT WITHOUT THE APPROVAL OF BUZZ INSURANCE. A COPY OF ANY QUOTE FOR REPAIRS SHOULD BE INCLUDED WITH THIS FORM. Accepted Date 1. INSURED DETAILS Policy Number Title Dr Mr Mrs Miss Ms Date of Birth (DD/MM/YYYY) First Name Last Name Address Post code Home Phone Work Phone Mobile Phone Email Prefer method of contact Home Work Mobile Email Insurance Australia Limited ABN 11 000 016 722 AFS License No. 227681 POSTAL ADDRESS PO Box 9871 Sydney NSW 2001 | FAX 1300 729 878 | EMAIL claims@thebuzzinsurance.com.au Page 1 2. DRIVERS DETAILS Was the vehicle being driven at the time of the incident? Yes No Driver: Driver or person last in charge of your vehicle Title Dr Mr Mrs Miss Ms Date of Birth (DD/MM/YYYY) First Name Last Name Address Post code Home Phone Work Phone Mobile Phone Email Prefer method of contact Home Work Mobile Email Driver's License No. Driver's License Expiry Date (DD/MM/YYYY) Number of years the licence held None (less than 1 year) 1 year 2 years 3 years 4 years 5 or more years Has the driver had any accidents, traffic convictions and /or penalties in last 5 years? Yes No If "Yes", given details - When Details Has the driver's licence ever been suspended or cancelled? Yes No If "Yes", given details - When State reason Had the driver consumed within 24 hours preceding the accident any drugs or alcohol? Yes No If "Yes", please state the nature, quantity and time of drugs and/or alcohol consumed Page 2 Were you required to take a blood, breath or urine tests? Blood Test Urine Test Alco-Test Full Breathalyser What was the reading? 3. YOUR VEHICLE'S DETAILS Registration Number Engine Number VIN Number Vehicle Make Vehicle Model Manufacture Year Was your vehicle used for business? Yes No Insured GST income tax credit % ABN 4. POLICE DETAILS Did the police attend the incident or have you notified them? Scene attended Self report No Police Station Police Report/Event Number Officer Name Station Phone Number Were any charges laid or indications made of further actions? Yes No If "Yes", please give details (who and what) Page 3 5. ACCIDENT/THEFT DETAILS Date of Accident Time Where did accident occur? Street Address Post code Do you accept liability of the accident? Yes No Loss Type Collision Collision involving another party Theft Malicious damage Natural disaster Fire Describe what happened Accident: Describe events before, during and after the accident (including no. of lanes, speed, parked, reversing etc.) Theft: Describe events from time parked until discovered missing (include who made discovery and any action) Page 4 Accident Sketch Please provide a sketch of the accident scene and show the vehicle(s) with the following identification: Your Vehicle Third Party Vehicle (s) Impact Point X Please provide the third party's registration number(s) below. Third Party1 Registration Number Third Party 2 Registration Number Third Party 3 Registration Number Checklist: Please show Street name Distances Lines/Lane Markings Traffic Signal/Signs Page 5 Accident What was the road surface like? Fine Wet Hail Fog Snow Theft State where vehicle was stolen from Was the vehicle locked? Yes No How many sets of key do you have? Where were the keys at the time? Who has each set of keys? Was the vehicle alarmed or fitted with an immobiliser? Yes No If "Yes", state which If "Yes", was alarm or immobiliser turned on? Yes No If not turned on, state reason Has the vehicle been recovered? Yes No If "Yes", by whom? Where has the vehicle been recovered? Was your vehicle damaged? Yes No Damage: On the diagrams show the point of impact by an 'X' and the areas damaged by shading Page 6 Do you consider the vehicle SAFE to drive? Yes No Is/was towing required? Yes No Towing: Towing Operator Name Phone Mobile Towing From Address Post code Towing To Address Post code 6. WITNESS DETAILS Were there any witnesses? Yes No Witness 1: Title Dr Mr Mrs Miss Ms First Name Last Name Address Post code Home Phone Work Phone Mobile Phone Email What is your relationship to the witness? Independent Known to our insured Known to third party Witness 2: Title Dr Mr Mrs Miss Ms First Name Last Name Address Post code Page 7 Home Phone Work Phone Mobile Phone Email What is your relationship to the witness? Independent Known to our insured Known to third party 7. THIRD PARTY DETAILS Were any vehicles, other than your own, involved in the accident? Yes No If yes, please answer the following questions. What is your relationship to the third party? Known Unknown Registration Number Vehicle Make Vehicle Model Manufacture Year Was the third party vehicle being driven at the time of incident? Yes No Driver Details: Title Dr Mr Mrs Miss Ms First Name Last Name Address Post code Home Phone Work Phone Mobile Phone Email License Number Third party's evidence of Impairment Alcohol/Drug usage Was the driver the vehicle owner? Yes No Unknown Page 8 Owner Details: Title Dr Mr Mrs Miss Ms First Name Last Name Address Post code Home Phone Work Phone Mobile Phone Email License Number Is the other party insured? Yes No Third Party Policy Number Insurer Name Claim Number Insurer Address Post code Third Party Damage: On the diagrams show the point of impact by an 'X' and the areas damaged by shading * If you have received any demands or notices from anyone, please submit with Claim Form. Page 9 8. REPAIRER DETAILS Repairer quote obtained? Yes No Unknown * If yes, please attach a copy of your quote to this claim form. If you have a preferred repairer, please provide the details below. Repairer Trading Name Address Post code Contact Name Phone Fax 9. DECLARATION I hereby authorise Buzz Insurance to obtain any report or statement that I have made to the police. I understand that the information provided in this claim form by me is true and correct. No information likely to affect this claim has been withheld. I understand that this claim may be refused if information is inaccurate or concealed. I consent to Buzz Insurance, in assessing or otherwise dealing with this claim, disclosing my personal information to or collecting my personal information from related entities, other insurers, insurance reference bureaux, investigators, or other parties providing services to the Insurer. Further information on how we handle your personal information, including how to access your information, is explained in our Privacy Charter. To get a copy of our Privacy Charter visit our website to view a copy. I authorise Buzz Insurance to obtain any report or statement that I have made to the police. Signature of INSURED INSURED Name Date (DD/MM/YYYY) When you have completed the form, print and sign. Please send the form to us by either by email, fax or mail. POSTAL ADDRESS : PO Box 9871 Sydney NSW 2001 FAX : 1300 729 878 EMAIL : claims@thebuzzinsurance.com.au Page 10

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