Motor Vehicle Claim Form - for online submission only do not scan, print or email.Download Print Version

Broker or dealer details
Company:
Name:
Phone:
Email:
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.
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.
Insured details
First name:
Family name:
Address:
Suburb:
State:	New South Wales Victoria Queensland Western Australia South Australia Tasmania Northern Territory
Postcode:
Phone:
Mobile:
Email:
Fax:
Policy number:
Policy expiry date:	Calendar
Insured vehicle details
Make:
Chassis number:
Model:
Registration:
Engine number:
Year:
Registration expiry:	Calendar
Speedometer reading (must be provided for any limited use policy):
Sum insured ($):
Was the vehicle being used for business or private use?:	Business Private
Damage sustained
Area damaged:
Upload photos of the body panels damaged in this accident (file format: gif;jpg;jpeg;png;zip):
Repairer’s name:
Repairer’s address
Street:
Suburb:
State:	-- Select State -- New South Wales Victoria Queensland Western Australia South Australia Tasmania Northern Territory
Postcode:
Phone:
Is the vehicle drivable?:	Yes No
Is the vehicle at repairer’s?:	Yes No
Address vehicle towed to
Street:
Suburb:
State:	-- Select State -- New South Wales Victoria Queensland Western Australia South Australia Tasmania Northern Territory
Postcode:
Date of accident:	Calendar(UTC + 10:00)
Place of accident:
Road conditions:	Wet Dry
Road conditions:	Daylight Dark
Your vehicle
>Estimated speed 100m prior to impact (kph):
Estimated speed on impact (kph):
Was your vehicle on the correct side of the road before the collision?:	Yes No
Was your vehicle on the correct side of the road after the collision?:	Yes No
Other vehicle
Estimated speed 100m prior to impact (kph):
Estimated speed on impact (kph):
Was their vehicle on the correct side of the road before the collision?:	Yes No
Was their vehicle on the correct side of the road after the collision?:	Yes No
Accident description
Accident description:
Plan of accident – Make an approximate plan of the scene of the accident showing the width of the roadway, positions of vehicles and persons involved and direction vehicles were traverling. If accident occurred at an intersection, show traffic lights, stops signs, pedestrain crossing, etc. Please mark insured vehicle as ‘A’ and other vehicles as ‘B’ etc. Show direction ‘>’, eg ‘A>’:
Details of driver of insured vehicle
Please provide a photocopy of your drivers licence with this claim form:
Name:
Date of birth:	Calendar
License no:
In the last 5 years prior to the inception of this policy, have you:
Had a motor vehicle stolen?:	Yes No
Details:
Lost your licence?:	Yes No
Details:
Had any traffic offences, fines or infringements?:	Yes No
Details:
Had any prior accidents and/or claims?:	Yes No
Details:
In the past 10 years, convicted of a criminal offense:	Yes No
Details:
Police or traffic officer details
Did police attend accident scene?:	Yes No
Officer’s name/Station attached to:
If no, was accident reported?:	Yes No
Was intoxicating liquor/drugs consumed by driver in 12 hours prior to accident?:	Yes No
If yes, how much and when?:
Was driver’s judgement impaired:	Yes No
Did police order any breathalyser or blood alcohol test?:	Yes No
Was a test taken?:	Yes No
What was reading:
Was driver driving with knowledge and consent of insured?:	Yes No
Who was responsible for the collision?:
Did any driver admit liability?:	Yes No
Whom:
Has a fine or on-the-spot fine been imposed?:	Yes No
Passenger details
1.
Name:
Address:
2.
Name:
Address:
Witness details
1.
Name:
Address:
2.
Name:
Address:
Other vehicle details
1.
Owners name:
Mobile phone:
Owners address:
Insurer:
Vehicle make:
Registration:
Drivers name:
Drivers licence:
Drivers address:
2.
Owners name:
Mobile phone:
Owners address:
Insurer:
Vehicle make:
Registration:
Drivers name:
Drivers licence:
Drivers address:
Property damage
Damage to property (fences, buildings, etc):
Persons injured:

Declaration

Privacy

We are committed to protecting your privacy. We will only use the personal information you have provided to us in settling this claim and any claim made against you in respect of the claim. You can check the personal information we hold by contacting our Privacy Officer on 03 9211 3700.

Read carefully before signing.

I/we acknowledge One Underwriting Pty Ltd may give to, or obtain from, other Insurers and/or Insurance/Financial Reference Bureau, State Licensing Authority, Parts or Service Providers, personal information in relation to this claim or my insurance in general. I/we hereby declare the foregoing particulars to be true and correct, and I/we undertake to render every assistance in my/our power in dealing with this matter.

I agree.

Your Duty of Disclosure:

Before You enter into a contract of insurance, You generally have a duty under the Insurance Contracts Act 1984 (Cth) (ICA) to disclose anything that You know, or could reasonably be expected to know, or in the case of consumer contracts (as defined in Part IV of the ICA) (Consumer Contracts) to take all reasonable care to disclose anything that You know, or could reasonably be expected to know, that may affect the insurer’s decision to insure You and on what terms. This includes Your driving record and insurance history for the previous five (5) years and any criminal convictions whether current or spent for the previous ten (10) years prior to the inception of, or renewal of the insurance Policy.
 
You have that duty after proposal, and up until the time the insurer agrees to insure You. You have the same duty before You renew, extend, vary or reinstate a contract of insurance.
 
You do not need to tell the insurer anything that:

• reduces the risk that is insured;
• is common knowledge;
• Your insurer knows or should know as an insurer; or
• the insurer waives compliance with Your duty of disclosure.

 
If You are uncertain about whether or not a particular matter should be disclosed to the insurer, please refer to any guidance issued in any insurance proposal or application form, Your Duty of Disclosure obligations contained in any PDS and Policy terms and conditions (as applicable) and contact Your appointed insurance broker or Us.

Non Disclosure:

If You fail to take reasonable care in disclosing information to us in the case of Consumer Contracts, or do not tell Your insurer anything You are required to, the insurer may cancel Your contract or reduce the amount that it is required to pay You if You make a claim, or both. If Your failure to disclose is fraudulent, the insurer may refuse to pay a claim and treat the contract as if it never existed.

I agree.

Short Form Privacy Disclosure and Consent

1. One Underwriting Pty Ltd is committed to protecting your personal information in accordance with the Australian Privacy Principles under the Privacy Act 1988 (Cth). We collect, use and disclose personal information to offer, promote, provide, manage and administer our various insurance services we are involved in as set out in the One Underwriting Privacy Notice. In order to do this, we may also share your information with other persons or entities who assist us in providing or promoting our services as set out in the One Underwriting Privacy Notice. Further information about our privacy practices can be located in the One Underwriting Privacy Policy, a copy of which can also be sent to you on request by your One Underwriting representative. You may also gain access to your personal information, or modify your privacy preferences, by contacting your One Underwriting representative or our Privacy Officer through the means set out in the One Underwriting Privacy Notice.
2. If you are disclosing personal or sensitive information about any other person to One Underwriting, you confirm that you have obtained the consent of that person to disclose to One Underwriting their personal or sensitive information and you have made them aware that One Underwriting will or may disclose their information to third parties that are reasonably necessary to assist in the provision of the relevant services or products. If you have not obtained consent from this other person to disclose their personal or sensitive information to One Underwriting, you will inform us before providing the relevant information to us.

By submitting this Claim Form, you acknowledge that you have read the One Underwriting Privacy Notice and agree that we can handle any personal information you have provided to us in the manner set out above Unless you tick here, we or any of our group of companies may be in touch by any means (including email or SMS) at any time to let you know about goods, services or promotions that may be of interest to you.

I agree.

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FOR ONLINE SUBMISSION ONLY DO NOT SCAN, PRINT OR EMAIL.