Motor Vehicle Accident Claim form

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1 Motor Vehicle Accident Claim form Complaints procedure Enthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no cost and aims to resolve claims complaints quickly and informally. In the unlikely event of a complaint arising, you should contact your local Enthusiast manager on In most cases the problem will be resolved easily. If you are not satisfied with the response given by your local enthusiast manager you may contact our Enthusiast Internal Dispute Resolution Committee for advice and assistance in resolving your claim. You may also wish to direct your concerns to the Company Secretary & General Counsel of Assetinsure Pty Ltd on (02) or If you remain not satisfied with a decision made by our Internal Dispute Resolution Committee, the matter may be referred to the Financial Ombudsman Services for their independent ruling, provided the matter falls within their jurisdiction. Financial Ombudsman Service Phone: Post: GPO Box 3, MELBOURNE Victoria 3001 Website: Privacy We respect your privacy and we comply with the Privacy Act and National Privacy Principles. A copy of Our Privacy ment is available from any of our offices or online at Enthusiast Claims PO Box 257 FERNY HILLS QLD 4055 Enthusiast Underwriting Pty. Ltd. ABN For prompt claims service this form must be returned to Enthusiast Underwriting, will all questions answered. Please print your answers and tick where appropriate. Office use only Claim number 1. Policy Holder Details Name/Business name Policy Number Address Phone Work Phone: Work Phone: Mobile Fax Number Occupation Page 1

2 2. Insured Vehicle Registration Number Year of Manufacture Make Model Body type Odometer Reading Expiry date of Registration Was there any unrepaired damage prior to the incident? Yes No When was the vehicle purchased? (year) Amount paid $ Is the vehicle under finance? Yes No Name of finance company Amount outstanding $ For what purpose was the vehicle being used at the time of the collision? Was any other insurance (other than Compulsory Third Party Insurance) in force on the vehicle at the time of the collision Yes No If yes state the name of the insurance company 3. Person in charge of the vehicle at the time of loss Name Date of Birth Address Phone Number Licence Number of Driver Date Issued Expiry Date Has the driver or insured had a policy cancelled, declined or higher excesses imposed in the past 5 years? Yes No if yes, please give details Has the driver been convicted of any traffic offence in the past 5 years? Yes No if yes, please give details Has the driver had their licence suspended in the past 5 years? Yes No if yes, please give details Has the driver consumed any Alcohol, drugs or Medication that day? Yes No If yes, how long before the accident? (hours) Type of Alcohol, Drugs or Medication Quantity consumed Has the driver made a claim in respect to a motor vehicle in the past 5 years? Yes No If yes list details below Page 2

3 4. The Accident When did the Accident Happen? Day Date Time am/pm Where did the accident happen? The road conditions at the time? Sealed Road Wet Dry Unsealed Road Wet Dry The Weather conditions at the time? Fine Overcast Rain Storm Hail The Lighting at the time? Day Night Dawn Dusk Estimated speed at the point of collision. a. Your Vehicle km/h b. The other vehicle km/h Did any driver admit fault? Yes No If yes who did? How did the accident happen? Describe in detail the circumstances leading up to and including the collision. It is important to be accurate. Do not hide facts or circumstances which may not be in your favour. Please print clearly. Please draw a diagram showing street, position of vehicles, direction of travel etc. Show North by arrow Symbols Your vehicle Other vehicle(s) Lane arrows Stop sign Street intersection Give way sign Curved street Traffic light Page 3

4 5. Damage to the Insured Vehicle Describe the damage to your vehicle directly resulting from this collision. On the Diagrams below show the point of impact by an X and the damaged areas by shading Your Vehicle Other Vehicle Is the vehicle driveable? Yes No Was it towed from the accident scene? Yes No If Enthusiast Underwriting needs to inspect the vehicle, please provide details of the contact person. Name Address of vehicle 6. Details of other vehicle and/or property Owners name Address Insurance Company Policy number Drivers name (if not insured) Address Drivers Licence Number Expiry date Vehicle details Year Make Model Registration number Details of property if not a vehicle (if space insufficient attach a separate sheet) Page 4

5 7. Witnesses Were there any witnesses to the collision? Yes No 1. Name Address Phone Home Phone Work Phone Mobile Type of Witness Passenger in your vehicle Passenger in other vehicle Independent eye witness 2. Name Address Phone Home Phone Work Phone Mobile Type of Witness Passenger in your vehicle Passenger in other vehicle Independent eye witness 8. Police (Please attach the police report to this claim form) Were the police advised of the accident? Yes No Did the police attend Yes No Which police station was the accident reported? Date? Police Report Number. Was any driver charged with an offence? Yes No Please give details below If a Breath analysis was conducted what were the results (please attach a copy) 9. Goods and services Tax (To ensure you not incur any unnecessary GST liabilities on this claim complete these details) Are you registered for GST purposes Yes No What is your ABN If you have registered and have an ABN, have you claimed or will you be claiming an input tax credit on the GST applicable to this policy Yes No Is the amount claimed less than 100% of the GST applicable to the premium. Yes No What is the percentage % 10. Electronic Funds Transfer (Settlement of your claim may involve a cash settlement. Please complete the following id you require an EFT payment) Account name BSB number Account Number 11. I declare all the information I have given is true and correct Signature of insured Date Signature of Driver Date Page 5

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