Compulsory Third Party Insurance Notice of Accident by Owner
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- Toby Reginald Melton
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1 Compulsory Third Party Insurance tice of Accident by Owner Please complete and mail to: CTP Claims, GPO Box 1453 Brisbane QLD 4001 Claim Reference. 1. OWNER Mr/Mrs/Ms Address (. & Street) Town/Suburb Postcode Phone (Work) (Home) (Mobile) Occupation Date of Birth 2. DRIVER Mr/Mrs/Ms Address (. & Street) Town/Suburb Postcode Phone (Work) (Home) (Mobile) Occupation Tick whether the driver was: Owner Authorised Driver Unauthorised Driver Date of Birth Licence. Expiry Date Class 3. DETAILS OF INSURED VEHICLE INVOLVED IN ACCIDENT Make Purpose of Use Model. of Persons in Vehicle (incl. driver) Regn. If, please provide the name of the Insurance Company and the Claim Number Was your vehicle comprehensively insured at the time of the accident Due Date Please tick the statement that applied to you at the renewal of your registration prior to the accident I was not registered for GST. (For example, this applies to most individuals who do not have a business.) I was registered for GST and entitled to claim an ITC. (For example, this applies to most businesses.) I was registered for GST but not entitled to claim an ITC. (For example, this applies businesses that are fully input taxed.) Is the above selection your current GST status and entitlement to claim an Input Tax Credit (ITC)? 4. DETAILS OF ACCIDENT Date of Accident Time (am/pm) Place - Street(s) Town/Suburb Postcode State quantity of alcohol/drugs consumed by the driver during the 12 hours prior to the accident Estimate speed of vehicle prior to accident kph Describe damage to vehicle Was the vehicle being used to or from work /03/14 A Did police attend accident scene Date Accident Reported Charge Police station to which accident reported Is Police action pending: Don t know Police Officer s Name If, against whom Insurance is provided by AAI Limited ABN trading as Suncorp Insurance. Suncorp-Metway Limited ABN and its related companies (except Suncorp Insurance) do not guarantee, and are not liable under, any insurance policies issued and services provided by Suncorp Insurance. Suncorp Insurance GPO Box 1453 Brisbane Qld 4001 Telephone
2 5. DETAILS OF OTHER VEHICLES INVOLVED IN THE ACCIDENT (If more, provide details on separate sheet) Make Model Make Model Registration. State Registration. State Owner s Name Owner s Name Owner s Address Owner s Address Driver s Name Driver s Name Driver s Address Driver s Address Describe Damage to Vehicle Describe Damage to Vehicle. of Persons in Vehicle (incl. driver). of Persons in Vehicle (incl. driver) 6. INJURED PERSON(S) DETAILS (If more, provide details on separate sheet) 7. WITNESSES OF THE ACCIDENT (including all passengers in the vehicle) Name Address Phone Name Address Phone Name Address Phone I declare the above information to be true and correct to the best of my knowledge and belief. Signature: Date PLEASE FORWARD ANY RELEVANT DOCUMENTS RECEIVED IMMEDIATELY
3 Brief description of the accident Who do you consider was responsible for causing the accident? Give reason for your opinion Did a vehicle fault or defect cause the accident? If yes, please provide the name and address details of the company who most recently serviced the vehicle and the date of the last service. Please make a rough plan of road, showing positions of vehicles and persons concerned at time of accident, and show with an arrow the direction in which they were travelling: Show your vehicle as A
4 Additional Information
5 PRIVACY STATEMENT AAI Limited trading as Suncorp Insurance is a member of the Suncorp Group, which we ll refer to simply as the Group. Why do we collect personal information? Personal information is information or an opinion about an identified individual or an individual who is reasonably identifiable. We collect personal information so that we can: identify you and conduct appropriate checks; administer and manage our products and services and systems, including the management and administration of underwriting and claims, recoveries and settlements; assess and investigate any claims made by our customers under their policies; assess and investigate any claims made by you against one of our customers; seek recovery from you due to any claim we or our customers may have against you; manage, train and develop our employees and representatives; manage complaints and disputes, and report to dispute resolution bodies; and get a better understanding of you, your needs, your behaviours and how you interact with us, so we can engage in product and service research, development and business strategy including managing the delivery of our services and products via the ways we communicate with you. What happens if you don t give us your personal information? If we ask for your personal information and you don t give it to us, we may not: be able to assess, investigate or manage the claim; or provide you and/or our customers with any or all entitlements under the policy How we handle your personal information We collect your personal information directly from you and, in some cases, from other people or organisations. We also provide your personal information to other related companies in the Group, and they may disclose or use your personal information for the purposes described in Why do we collect personal information? in relation to products and services they may provide. They may also use your personal information to help them provide products and services to other customers, but they ll never disclose your personal information to another customer without your consent. Under various laws we will be (or may be) authorised or required to collect your personal information. These laws include the Anti-Money Laundering and Counter-Terrorism Financing Act 2006, Personal Property Securities Act 2009, Corporations Act 2001, Autonomous Sanctions Act 2011, Motor Accident Insurance Act 1994 (QLD), Motor Accident Insurance Regulation 2004 (QLD), Public Trustee Act 1978 (QLD), Workers Compensation and Rehabilitation Act 2003 (QLD), Transport Operations (Road Use Management) Act 1995, Uniform Civil Procedure Rules 1999, Queensland Civil and Administrative Tribunal Act 2009, Right to Information Act 2009, Health and Other Services (Compensation) Act 1995, Social Security Act 1991, Income Tax Assessment Act 1997, Income Tax Assessment Act 1936, Income Tax Regulations 1936, Tax Administration Act 1953, Tax Administration Regulations 1976, A New Tax System (Goods and Services Tax) Act 1999, as those laws are amended and includes any associated regulations We will use and disclose your personal information for the purposes we collected it as well as purposes that are related, where you would reasonably expect us to. We may disclose your personal information to and/or collect your personal information from: the claimant, insured, policy or product holder, or witnesses other companies within the Group and other trading divisions or departments within the same company (please see our Group Privacy Policy for a list of brands/companies); any of our Group joint ventures where authorised or required; customer, product, business or strategic research and development organisations; data warehouse, strategic learning organisations, data partners, analytic consultants; publicly available sources of information; a third party that we ve contracted to provide financial services, financial products or administrative services for example: information technology providers, administration, actuarial, insurance or business management services, consultancy firms, auditors and business management consultants, marketing agencies and other marketing service providers, claims management service providers print/mail/digital service providers, and imaging and document management services; any intermediaries, including your agent, adviser, a broker, representative or person acting on your behalf, other Australian Financial Services Licensee or our authorised representatives, advisers and our agents;
6 PRIVACY STATEMENT (continued) accounting or finance professionals and advisers; government, statutory or regulatory bodies and enforcement bodies; the Financial Ombudsman Service or any other external dispute resolution body; credit reporting agencies; other insurers, reinsurers, insurance investigators and claims or insurance reference services, loss assessors, financiers; legal and any other professional advisers or consultants; hospitals and, medical, health or wellbeing professionals; debt collection agencies; any other organisation or person, where you ve asked or authorised them to provide your personal information to us or asked or authorised us to obtain personal information from them, eg your mother. We ll use a variety of methods to collect your personal information from, and disclose your personal information to, these persons or organisations, including written forms, telephone calls and via electronic delivery. We may collect and disclose your personal information to these persons and organisations during the information life cycle, regularly, or on an ad hoc basis, depending on the purpose of collection. Overseas Disclosure Sometimes, we need to provide your personal information to or get personal information about you from persons or organisations located overseas, for the same purposes as in Why do we collect personal information? The complete list of countries is contained in our Group Privacy Policy, which can be accessed at or you can call us for a copy. From time to time, we may need to disclose your personal information to, and collect your personal information from, other countries not on this list. Nevertheless, we will always disclose and collect your personal information in accordance with privacy laws. How to access and correct your personal information or make a complaint You have the right to access and correct your personal information held by us and you can find information about how to do this in the Suncorp Group Privacy Policy. The Policy also includes information about how you can complain about a breach of the Australian Privacy Principles and how we ll deal with such a complaint. You can get a copy of the Suncorp Group Privacy Policy. Please use the contact details in Contact Us. Contact us For more information about our privacy practices including accessing or correcting your personal information, making a complaint, or obtaining a list of overseas countries you can: Visit Speak to us by phoning us at ctpbiz@suncorp.com.au
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Claim : Corporate Travel and Personal Accident Insurance Claim Form Prepared 03 January 2012 Email: travelclaims@allianzassistance.com.au Phone: 1800 761 173 Facsimile: (07) 3360 7854 Postal Address: Claims
Motor Vehicle Insurance Claim. Insured
INSURANCE BROKERS 22 Welsford Street, Shepparton PO Box 1377, Shepparton VIC 3632 www.ggib.com.au Phone (03) 5821-7777 Fax (03) 5822-2916 Email ggib@ggib.com.au ABN 52 858 454 162 AFS 237 533 Motor Vehicle
Personal Accident and Sickness Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Employer: Claimants Name: Job
Personal Accident Claim Form
Corporate Services Network ABN 30 074 864 609 Level 2 280 George Street Sydney NSW 2000 Ph: 61 2 8256 1770 Fax: 61 2 8256 1775 www.csnet.com.au e-mail: claims@csnet.com.au Personal Accident Claim Form
Motor Vehicle Insurance Claim
Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged
PUBLIC/PERSONAL LIABILITY CLAIM FORM
ACE Insurance Limited PUBLIC/PERSONAL LIABILITY CLAIM FORM McKenna Hampton Pty Ltd "Kandahar House" Level 1, 41-43 Ord Street West Perth WA 6005 PO Box 204, West Perth WA 6872 Phone: 08 6142 0000 Fax:
ABN ACN Registration number (including ABN of any Trust) (company applicants only) (incorporated association applicants only) Business phone number:
on 1300 658 108 Mon to Fri 9am-5pm (AEST/AEDT) Mail to New Accounts - Business Banking, ME Bank, Reply Paid 1345, Melbourne, Victoria 8060. Visit mebank.com.au Section 1 - Applicant Details Business Loan