Broker or dealer details
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.
- 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 vehicle details
|Was the vehicle being used for business or private use?:|
|Is the vehicle drivable?:|
|Is the vehicle at repairer’s?:|
Address vehicle towed to
|Was your vehicle on the correct side of the road before the collision?:|
|Was your vehicle on the correct side of the road after the collision?:|
|Was their vehicle on the correct side of the road before the collision?:|
|Was their vehicle on the correct side of the road after the collision?:|
Details of driver of insured vehicle
In the last 5 years prior to the inception of this policy, have you:
|Had a motor vehicle stolen?:|
|Lost your licence?:|
|Had any traffic offences, fines or infringements?:|
|Had any prior accidents and/or claims?:|
|In the past 10 years, convicted of a criminal offense:|
Police or traffic officer details
|Did police attend accident scene?:|
|If no, was accident reported?:|
|Was intoxicating liquor/drugs consumed by driver in 12 hours prior to accident?:|
|Was driver’s judgement impaired:|
|Did police order any breathalyser or blood alcohol test?:|
|Was a test taken?:|
|Was driver driving with knowledge and consent of insured?:|
|Did any driver admit liability?:|
|Has a fine or on-the-spot fine been imposed?:|
Other vehicle details