Broker or dealer details |
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Guide for completion |
Please complete all sections of this form and note the following: - The completion of this form does not constitute policy acceptance by the insurer.
- Failure to notify a matter immediately after the event or after you become aware of the event may enable the insurer to reduce or avoid any liability incurred.
- Please ensure that you answer all questions in full and honestly. The form must be signed and dated.
- If you do not believe a question is applicable, please write ‘n/a’.
- Original hard copy records are required by the insurer. Should you require them to be returned, please include a written request advising same. Photocopies are not acceptable for audit reasons.
- All communications should be marked ‘Private and Confidential’.
- If anyone holds you responsible for their accident or injury, please insist that their claim must be in writing.
- Do not admit liability to any claimant and do not disclose to the claimant the existence of any insurance you may have in place.
- If there is insufficient space or further comment on any area is considered necessary, please use additional pages.
- Salvage remains the property of the insurer, until such time as advised otherwise by the insurer.
- Any attachments will form part of this claim report and the declaration will include them.
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To ensure prompt attention to your claim, please complete this form in full and leave it with your vehicle for assessment. Note: - Ensure the accident description is accurate and all questions on the claim form have been answered in full.
- Obtain one quotation from a repairer of your choice.
- Repairs may not be commenced without written authority from One Underwriting Pty Ltd.
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Insured details |
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Insured vehicle details |
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Was the vehicle being used for business or private use?: |
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Damage sustained |
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Repairer’s address |
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Is the vehicle drivable?: |
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Is the vehicle at repairer’s?: |
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Address vehicle towed to |
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Road conditions: |
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Road conditions: |
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Your vehicle |
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Was your vehicle on the correct side of the road before the collision?: |
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Was your vehicle on the correct side of the road after the collision?: |
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Other vehicle |
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Was their vehicle on the correct side of the road before the collision?: |
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Was their vehicle on the correct side of the road after the collision?: |
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Accident description |
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Details of driver of insured vehicle |
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In the last 5 years prior to the inception of this policy, have you: |
Had a motor vehicle stolen?: |
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Lost your licence?: |
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Had any traffic offences, fines or infringements?: |
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Had any prior accidents and/or claims?: |
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In the past 10 years, convicted of a criminal offense: |
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Police or traffic officer details |
Did police attend accident scene?: |
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If no, was accident reported?: |
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Was intoxicating liquor/drugs consumed by driver in 12 hours prior to accident?: |
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Was driver’s judgement impaired: |
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Did police order any breathalyser or blood alcohol test?: |
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Was a test taken?: |
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Was driver driving with knowledge and consent of insured?: |
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Did any driver admit liability?: |
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Has a fine or on-the-spot fine been imposed?: |
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Passenger details |
1. |
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2. |
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Witness details |
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2. |
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Other vehicle details |
1. |
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2. |
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Property damage |
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