MOTOR VEHICLE CLAIM FORM (Accident or Theft)

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1 Cowden Group MOTOR VEHICLE CLAIM FORM (Accident or Theft) The supply or acceptance of this form is not an admission of liability on the part of your Insurer 1. Your Details Policy No Expiry of Insured Occupation Contact Person Contact Numbers Postal Suburb Are you registered for GST? Yes No ABN Are you entitled to claim Input Tax Credit? Yes No Please specify the percentage amount claimed or intended to be claimed % 2. Insured Vehicle Details Registration No Engine No VIN of registered owner Make, Model & Body Type Year Do you owe money on the vehicle? Yes No If yes, Lender's name and approximate amount owing $ Has the vehicle been modified or converted from the manufacturer's specification or fitted with accessories other than those supplied by the manufacturer? No Yes If yes, describe the modifications / accessories below: Was there any unrepaired damage to the vehicle before the accident? No Yes If yes, describe the unrepaired damage below:

2 3. Driver Details Driver's Date of Birth Phone Mobile Licence No Expiry Class Years held an Australian Drivers Licence Relationship to Insured? Was the vehicle being used with the Insured's consent? Yes No Was the vehicle being used for business or private purposes? How often does the driver use the vehicle in a year? Did the Driver consume any alcohol or drugs during the 12 hours Before the accident? Yes No Quantity Was the Driver tested by the Police for alcohol or drugs? Yes No If yes, what was the results: Does the Driver hold motor insurance on any other vehicle? Yes No If yes, provide details of Insurer and policy number: 4. Accident or Theft Details Date of Occurrence Time of Loss am / pm Location Accident: Describe events before, during and after the accident (no. of lanes, speed, parked, reversing etc) Using the symbols below draw a diagram of the accident scene showing the position of all the vehicles. Indicate by arrows the direction in which the vehicles were travelling, the names of the streets and the north point of the compass. Please identify any other vehicles involved as 2, 3, 4 etc. It is important that the sketch be as accurate and as detailed as possible as it may be used in legal proceedings.

3 What were the road conditions at the time of the accident? Wet Dry Sealed Roadway Unsealed Roadway What were the weather conditions at the time of the accident? Fine Overcast Storm Raining Hail Other At the time of the accident what was the approximate speed before braking of the: Insured Vehicle km/h Other vehicle km/h Theft: Describe events from time parked until discovered missing (including who made discover & any action taken) Was the vehicle locked? Yes No Were the keys duplicated? Yes No Where were the keys at the time? Who has each set of keys? Was the vehicle alarmed or fitted with an immobiliser? Yes No If yes, was alarm or immobiliser turned on? Yes No If not turned on, state reason? Has vehicle been recovered? Yes No If yes, by whom? Where recovered? (if recovered, please complete damaged section of claim form) On the diagram please shade the areas damaged in the accident/theft Is the vehicle driveable? Yes No If vehicle towed, state by whom Where can the vehicle be inspected? 5. Other Vehicle(s) Details Owners Details: Insurance Company Make, Model & Body Type Year Registration No

4 Driver Details: Licence No Date of Birth Please shade the damaged areas of the other vehicle damaged in the accident: Was there any admission of responsibility for the accident? Yes No If yes, give details: As a result of the accident, was there any other property damaged (fences, poles etc)? If yes, provide details including name and address of owner: 6. Witnesses Were there any witnesses to the event? Yes No If yes, please complete this section: Witness 1: Where was the Witness? Witness 2: Phone No Where was the Witness?

5 7. Police Please state below whether the Police were notified No Yes State Reason of Officer Police Station Police Report No Date Did the Police attend the scene? Yes No Were any charges laid or indications made of further action? Yes No If yes, give details (who and what) 8. History Have you or the driver had any insurance or renewal of insurance declined or cancelled or special conditions imposed in the last 5 years? Yes No Have you or the driver been convicted of or had any fines or penalties imposed for any criminal offence? Yes No Have you or the driver had an accident or made a claim on a motor vehicle insurance policy in the last 5 years? Yes No Have you or the driver been convicted of or had any fines or penalties imposed for any driving offence in the last 5 years? Yes No If yes to any History questions, please give details: 9. Declaration I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information. I consent to the insurer using my personal information I have provided on this form for the purpose of processing my claim. I understand that if I choose not to provide the required details, this is my choice however, the insurer may not be able to process the claim. I consent to the insurer disclosing my personal information to other insurers, an insurance reference service or as required by law. I consent to the insurer also disclosing my personal information to and/or collecting additional information about me, from investigators or legal advisors. Insured Driver Signature Signature Date Date When complete, please forward the claim form, together with all attachments to your local Cowden office (refer below) Cowden Limited PO Box 60, West Perth WA 6872 Cowden (SA) Pty Ltd PO Box 744, Unley SA 5061 Cowden (VIC) Pty Ltd PO Box 33044, Melbourne VIC 3004 Cowden (NSW) Pty Ltd PO Box 673, Parramatta NSW 2124

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