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Home
About Us
Our History
Our Team
Steadfast
Why use a broker?
Code of Practice
How to make a payment
Insurance Solutions
Business Insurance
Business Insurance Quote Request
Domestic & Personal Insurance
Travel Insurance
Claims
News
Compliance
Disclaimer
Dispute Resolution
Financial Services Guide
Privacy Policy
Important Notices & Information
Target Market Determination – Steadfast
Contact
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 beforehand, no repairs or alterations to the damaged vehicle should be made unless approved by your insurance underwriter.
Policy Number
Client Ref No.
Insured
Insured’s Name
Address
Postcode
Phone No.
Occupation
Email
What is your Australian Business Number (ABN)?
Are you registered for GST?
Yes
No
To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?
Are you the sole owner of the insured vehicle?
Yes
No
If NO, who is the owner?
Insured Vehicle
Make & Model
Year
Rego Number
Rego Expiry Date
Colour
Class of Vehicle
Sedan or Station Wagon
Van or Utility up to 2T
Rigid Vehicle over 2T and up to 5T
Rigid Vehicle over 5T and up to 10T
Rigid Vehicle over 10T
Articulated Prime Mover
Bus or Coach
Light Construction or Earthmoving Plant
Heavy Construction or Earthmoving Plant
Trailer
Other
Trailer Details (if applicable)
Make
Type
Year
Registration No.
Driver
If the vehicle was unattended, who was responsible for the vehicle at the time of the loss.
Surname
Given Name(s)
Address
Postcode
Phone No.
Date of Birth
Gender
Male
Female
Driver Licence
Expiry Date
Years Held
Registered Owner of Vehicle
Are you an employee?
Yes
No
If not, state
Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years
Yes
No
If Yes, please give details including dates and circumstances.
Did you consume any alcohol or take drugs during the 12 hours prior to the accident?
Yes
No
If Yes, what was consumed, in what quantities and when consumed.
Did you undergo a breath test or blood test for alcohol or drugs?
Yes
No
If Yes, what was the result.
Did you refuse to undergo any of the above tests?
Yes
No
Damage to Insured Vehicles
Was your vehicle damaged?
Yes
No
Was your vehicle towed away?
Yes
No
Have you obtained a repair quote?
Yes
No
Repair quote amount $
(Attach Quote)
File
Max. file size: 2 MB.
If you are unable to attach a quote, please advise the name of the repairer, their contact details and quote number
Name of repairer
Contact details
Quote number
If not driveable, what is the full address where the vehicle can be inspected?
Phone No.
Describe in detail where the damages appear on your vehicle.
Accident Details
Business or private?
Business
Private
Date
Time
Vehicle Use:
What was the accident location?
Street
Suburb
P/Code:
How did the accident happen?
Who do you consider was at fault?
Myself
Other Driver
Something Else
Describe what / who else was at fault
Estimated speed of YOUR vehicle just before the accident
Estimated speed of OTHER vehicle just before the accident
What was the condition of the road?
Sealed
Unsealed
Smooth
Rough
Wet
Dry
How was visibility?
Good
Moderate
Poor
Were there any witnesses to the accident?
Yes
No
If yes, please provide name/s, address/s and phone number/s.
Did Police attend the accident?
Yes
No
Police Station
Name/Number of Officer
If No, state time and date reported to Police
Did Police indicate who was responsible?
Yes
No
If Yes, Name of Driver
Did Police charge either driver or suggest action may be taken?
Yes
No
Charge
Damage to Other Vehicle or Property
Vehicle or Property No. 1
Name of other driver:
Age:
Phone:
Licence No:
Vehicle Make & Model:
Rego No:
Name of Registered Owner:
Address:
Phone:
The Other Insurance Company:
Policy Number:
Description of Damage
Vehicle or Property No. 2
Name of other driver:
Age:
Phone:
Licence No:
Vehicle Make & Model:
Rego No:
Name of Registered Owner:
Address:
Phone:
The Other Insurance Company:
Policy Number:
Description of Damage
Personal Injuries
Was anyone injured in the accident?
Yes
No
Person A
Name
Type of Injury
Injured Party (Passenger/Driver)
Vehicle (Registration No.)
Person B
Name
Type of Injury
Injured Party (Passenger/Driver)
Vehicle (Registration No.)
Privacy
The Privacy Act 1988 requires us to tell you that we as broke and the insurer collect your personal and sensitive information in order to calculate your loss and entitlements, determine the insurer’s liability, compile data and handle claims. When handling claims we and the insurer may have to disclose your personal and other information to third parties such as other insurers, reinsurers, loss adjusters, external claims data collectors, investigators and agents, or other parties as required by law. Where you give us information about other persons you must have their consent to this and provide it on their behalf. If not, you must tell us. You have the right to seek access to your personal information and to correct it at any time. Please contact us to advise if any changes are required.
Internal Dispute Resolution (IDR) Statement
Disputes are not an everyday occurrence. However insurers provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of that process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).
Declaration
1. I/We the insured do solemnly and sincerely declare that I/We have complied with the conditions and warranties (if any) of the policy and have not deliberately caused the said loss or damage or sought unjustly to benefit thereby by any fraud or misrepresentation and that the information shown on the form is true and the I/We have not concealed any information relating to this claim. I/We understand that this claim may be refused if the information is untrue, inaccurate or concealed. 2. Further it is understood and agreed that if any property claimed for is subsequently recovered in an undamaged condition I/We will immediately refund the company any sum which may have been paid to me/us in respect of such property. In the event of any property being recovered in damaged condition I/We will immediately hand the same over to the company for disposal as may be agreed. 3. I/We acknowledge that I/We have read and understood the Privacy Act information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. 4. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information, then the broker and the insurer will be unable to process my/our claim.
Name of Driver
Date
MM slash DD slash YYYY
Name of Insured
Date
MM slash DD slash YYYY
How To Make A Motor Vehicle Claim
Whether at fault or not and to avoid delay, it is easier to claim on your Insurer and let them recover for you. Here are the steps to be taken: -
1.
Obtain a quotation from a reputable repairer.
2.
The repairer will usually arrange the assessment and for this you must: -
a) Compete a claim form,
b) Supply a copy of your licence to be left with the claim form at the repairers.
3.
On the day of the assessment (to be pre-arranged with you), the vehicle should be left all day with your repairer, repairs should be authorised on that day and work can commence. You will pay your excess to the repairer when collecting the repaired vehicle.
If you are not at fault: -
•
Your excess is recoverable
•
Car hire may be paid for, if a business registered vehicle, but not necessarily all costs. Please note, the refund of excess and car hire is paid by the third party or their Insurer and thi9s usually takes between 3-6 months. If not refund received after 6 months, you can: -
•
Follow this up yourself by contacting your Insurer
•
Contact our office and ask our assistance.
4.
In the event of a total loss, the
market
value will be determined by the assessor. At times you may not agree on this figure, however, it is your prerogative to obtain another valuation. We can advise.
5.
If the vehicle has been stolen, your Insurer will apply for a Police report. They will generally wait for 4-6 weeks before settling the claim in the event the vehicle is recovered (80% usually are recovered albeit not in the condition when last seen by the owner).
6.
If your vehicle is not damaged or damage is minor but you have caused damage to an third party and the accident is your fault, a claim form must be completed and sent to our office with a copy of your licence and excess if applicable, and then forward any letters of demand with quotations.
Please provide bank details in order for your claim payment to be settled via EFT.
BSB Number:
Bank Account Number:
Name of Bank:
Account Holder Name
Please type your name below to agree to our terms
Name
This field is for validation purposes and should be left unchanged.
