Motor Vehicle Claim (Non Theft) | Aughtersons Insurance

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Motor Vehicle Claim Form

Non theft motor vehicle claim form.

Step 1 of 14

7%

Motor Vehicle Claim Form (Non theft)

The issue of this form does not constitute an admission of liability on the part of the insurer.

Save and Continue: If you need to, you may save and continue completing this form at a later time. Click the 'save and continue later' link at the bottom of any page to do so.
NOTE: Do NOT use the back button in your browser, use the PREVIOUS/NEXT buttons at the bottom of each page to go back and forward.

Important: Please complete all sections.

AND Attach one quotation from repairer (at the end before submitting).
The Insured
Name*
First Last
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you registered for GST?*
- Yes
- No
What is your ABN?*
Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable to the Policy?*
- Yes
- No
Will you be claiming an amount less than 100%?
- Yes
- No
Specify the percent amount claimed
Are you entitled to claim an input tax credit for repairs or replacement of the item that has been lost or damaged?*
- Yes
- No
If yes, will you be claiming an amount less than 100%?
- Yes
- No
Specify the percent amount claimed
Business*
Private
Facsimile
Mobile

Vehicle Details
Make of Vehicle*
Model*
Year*
Colour*
Registered No.*
Odometer Reading*
Registered Owner*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you owe money on your vehicle?*
- Yes
- No
Name of Lender
Account Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver Details
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Business
Private
Fax
Mobile
Relationship to Insured*
Date of Birth*
Licence Number*
Expiry*
How long has the driver been licensed for this type of vehicle?*
Did the driver drink any alcohol or take any drugs in the 24 hours prior to the accident?*
- Yes
- No
If yes, give details
Did the driver undergo a breath test, breath analysis or blood test?*
- Yes
- No
If yes, what was the reading?
Please attach a copy of the certificate?

Incident Details
Date of Incident*
Date Format: MM slash DD slash YYYY
Day of Incident*
Time of Incident*

: HH

MM
Where did the incident happen?*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Road Surface*
- Dry
- Wet
- Loose
At the time of the incident, the insured vehicle was*
- Parked
- Stationary
- Moving
If moving, at what speed.
Traffic controls*
- None
- Stop sign
- Traffic Lights
- Roundabout
- Give way sign
Number of other vehicles involved?*
If applicable, what type of goods were being transported at time of loss?
What happen?*
Who was at fault?*
Given Name Surname
Please attach a sketch diagram of accident.
Include:
1. Name streets.
2. Indicate direction of travel.
3. Your Vehicle.
4. Other vehicle.
Accepted file types: pdf, jpg, png.

Damage To Your Vehicle
Are you claiming for the damage to your vehicle?
- Yes
- No
Was the vehicle towed?
- Yes
- No
Name of towing company
Where was it towed?
Distance towed (kms)
Where is the vehicle now?
Describe the damage to your vehicle, including point of impact.
For example. Front bumper dented, right side passenger door dented and scratched, front right headlight broken etc.

Owner of Other Vehicle
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Business
Phone Private
Insurance Company
Policy No.

Driver of Other Vehicle
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Date of Birth
Driver's Licence Number
Was the owner in the vehicle at the time of the accident?
- Yes
- No

Other Vehicle
Registration No.
Year of Manufacture
Make of Vehicle
Model
Colour
Describe the damage to the other vehicle, including point of impact.
For example. Front bumper dented, right side passenger door dented and scratched, front right headlight broken etc.

Other Parties
Give details of pedestrians, owners of property of owners of animals involved.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Police
Did the police attend the accident scene?
- Yes
- No
Or did you report the incident to the police?
- Yes, give details below
- No
Name
First Last
Rank
Station
Date of Report
Date Format: MM slash DD slash YYYY
Attach copy of the report
Accepted file types: pdf, jpg, png.
Name of person to be charged or cautioned
First Last
Nature of charge or caution

Witness(es) Details
Witness 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Was this witness in the insured vehicle?
- Yes
- No
Witness 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Was this witness in the insured vehicle?
- Yes
- No

Owner(s) and Driver History
In the last 5 years have you as owner or the driver of this vehicle:
1. Has an insurance refused, declined or cancelled by an insurer or any special conditions imposed?*
- Yes
- No
2. Been convicted or charged with:
a. Drug use, driving under the Influence, or exceeding Prescribed Concentration of Alcohol?*
- Yes
- No
b. Any driving offences or speeding infringements?*
- Yes
- No
c. Fraud, arson, theft or any other criminal act?*
- Yes
- No
3. Had a drivers or motorcycle licence cancelled, suspended or endorsed?*
- Yes
- No
4. Had a claim or accident?*
- Yes
- No
5. Had a car stolen or burnt out?*
(include any not reported or not claimed from an insurer)
- Yes
- No
6. Suffered or suffer from any impaired eyesight (excluding wearing of glasses), loss of or use of any limb or loss of hearing of from any physical defect or epileptic, diabetic, heart or mental condition?*
- Yes
- No

If you answered yes to any of the above questions, please provide relevant details below.

Name of Driver	Date of Incident	Details of Incident	Insurer	Person at Fault

Quotation
Please attach ONE quotation from repairer here.
Accepted file types: pdf, jpg, png.

Declaration and Authorisation
The information and answers given above are true and complete in every detail.
I understand the claim may be refused or reduced if information if withheld.
The Insured
Name of Insured
First Last
Signature
Date
Date Format: MM slash DD slash YYYY
The Driver
Name of Driver
First Last
Signature
Date
Date Format: MM slash DD slash YYYY
Please check that this claim form has been fully completed as any omissions may delay your claim.*
Click below to enable your claim to be submitted.
- Yes
- No
Name
This field is for validation purposes and should be left unchanged.

Contact

Tel: (03) 9879 7699
Fax: (03) 9879 7155
Email: insurance@augib.com.au

Important Information

AFSL 227 200
ABN 90 007 367 535
Privacy Policy

Links

NIBA
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Motor Vehicle Claim Form

Step 1 of 14

Motor Vehicle Claim Form (Non theft)

The Insured

Vehicle Details

Driver Details

Incident Details

Damage To Your Vehicle

Owner of Other Vehicle

Driver of Other Vehicle

Other Vehicle

Other Parties

Police

Witness(es) Details

Owner(s) and Driver History

Quotation

Declaration and Authorisation

The Insured

The Driver

Contact

Important Information

Links