One Underwriting - Motor Vehicle Claim Form

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 to take Reasonable Care not to Misrepresent

You have a duty to take reasonable care not to make any misrepresentation when entering into, varying, extending or renewing the Policy. This means that it is essential that You respond to specific questions that We ask honestly and to the best of Your knowledge, including where We ask You to confirm or update information that You have previously given to Us when entering into, varying, extending or renewing the Policy.

For example this will include You or any other persons to be covered under this Policy and their driving record, claims (or incidents unclaimed or uninsured for), criminal and insurance history. This duty also extends to, but not limited to how Your Vehicle is Garaged, registered or used in frequency and nature of use for example Private Use, Business Use or otherwise.

To assist You with providing Us with honest and accurate responses to any questions We ask of You, We have endeavored to ensure that any question We ask are clear and easy to understand. Further, where possible, We have also included examples of the types of responses We are looking for when asking a particular question.

If You are unclear of any particular question or would like Us to explain it to You, please get in touch with Us and We will explain this to You.

In determining whether You have fulfilled this duty to take reasonable care not to make a misrepresentation to Us, We will consider all of the relevant circumstances of a particular case. If You do not respond honestly and accurately to specific questions that We ask, We may (acting reasonably) cancel Your contract or reduce the amount We will pay You if You make a claim, or both. It is therefore vital that You be honest and specific in Your responses. If Your failure to tell Us is fraudulent, We will refuse to pay a claim and treat the Policy as if it never existed (this does not mean that We will refund any premiums that You have already paid).

I agree.

Short Form Privacy Disclosure and Consent

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.
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 and you agree for One Underwriting Pty Ltd or Aon to send me information about its goods, services and promotions via email or phone.

I agree.

Broker or dealer details
Company:
Name:		Please enter a value.
Phone:		Please enter a value.
Email		Please enter a value.
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:		Please enter a value.
Family name:		Please enter a value.
Address:		Please enter a value.
Suburb:		Please enter a value.
State:		Please enter a value.
Postcode:		Please enter a value.
Phone:		Please enter a value.
Mobile:
Email:		Please enter a value.
Fax:
Policy number:		Please enter a value.
Policy expiry date:
Insured vehicle details
Make:		Please enter a value.
Chassis number:
Model:		Please enter a value.
Registration:		Please enter a value.
Engine number:
Year:		Please enter a value.
Registration expiry:		Please enter a value.
Speedometer reading (must be provided for any limited use policy):		Please enter a value.
Sum insured ($):
Was the vehicle being used for business or private use?:	Business Private	Please enter a value.
Damage sustained
Area damaged		Please enter a value.
Upload photos of the body panels damaged in this accident (file format: gif;jpg;jpeg;png;zip):		Please select a file.
Repairer’s name:
Repairer’s address
Street:
Suburb:
State:
Postcode:
Phone:
Is the vehicle drivable?:	Yes No	Please enter a value.
Is the vehicle at repairer’s?:	Yes No	Please enter a value.
Address vehicle towed to
Street:
Suburb:
State:
Postcode:
Date of accident:	(UTC + 10:00)	Please enter a value.
Place of accident:		Please enter a value.
Road conditions:	Wet Dry	Please enter a value.
Road conditions:	Daylight Dark	Please enter a value.
Your vehicle
>Estimated speed 100m prior to impact (kph):		Please enter a value.
Estimated speed on impact (kph):		Please enter a value.
Was your vehicle on the correct side of the road before the collision?:	Yes No	Please enter a value.
Was your vehicle on the correct side of the road after the collision?:	Yes No	Please enter a value.
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 Please enter a value.
Do you have Dash Cam footage of the incident?:	Yes No
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:		Please select a file.
Name:		Please enter a value.
Date of birth:		Please enter a value.
License no:
License Expiry Date:
Number of Years Licences in Australia:
In the last 5 years prior to the inception of this policy, have you:
Had a motor vehicle stolen?:	Yes No	Please enter a value.
Details
Lost your licence?:	Yes No	Please enter a value.
Details
Had any traffic offences, fines or infringements?:	Yes No	Please enter a value.
Details
Had any prior accidents and/or claims?:	Yes No	Please enter a value.
Details
In the past 10 years, convicted of a criminal offense:	Yes No	Please enter a value.
Details
Police or traffic officer details
Did police attend accident scene?:	Yes No	Please enter a value.
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	Please enter a value.
If yes, how much and when?:
Was driver’s judgement impaired:	Yes No	Please enter a value.
Did police order any breathalyser or blood alcohol test?:	Yes No	Please enter a value.
Was a test taken?:	Yes No	Please enter a value.
What was reading:
Was driver driving with knowledge and consent of insured?:	Yes No	Please enter a value.
Who was responsible for the collision?:		Please enter a value.
Did any driver admit liability?:	Yes No	Please enter a value.
Whom:
Has a fine or on-the-spot fine been imposed?:	Yes No	Please enter a value.
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:

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

Broker or dealer details

Guide for completion

Insured details

Insured vehicle details

Damage sustained

Repairer’s address

Address vehicle towed to

Your vehicle

Other vehicle

Accident description

Details of driver of insured vehicle

In the last 5 years prior to the inception of this policy, have you:

Police or traffic officer details

Passenger details

Witness details

Other vehicle details

Property damage

Declaration

Privacy

Read carefully before signing.

Your Duty to take Reasonable Care not to Misrepresent

Short Form Privacy Disclosure and Consent