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Motor

Liability

Property

1. Insured Details

Claim Type*

Motor Policy Number

Property Policy Number

Liability Policy Number

Insured Name

Reference Number

Dealership

Department

Insured's Address

Insured's Email*

Insured's Phone Number*

Select State*

Are you registered for GST?

Yes

What is your Australian Business Number (ABN)?

Are you entitled to claim on input tax credit on this policy?

Yes

Input Tax Credit %

2. Driver Details

For parked or unattended vehicles, Driver = Vehicle custodian at time of loss

Drivers Name

Driver Address

Driver Email

Driver Phone Number

Driver Date of Birth

Drivers Licence Number

Drivers Licence Expiry Date

Drivers Licence Years Held

Any traffic convictions or been involved in any motor vehicle accidents in the past 5 years?

Yes

Please give details of conviction or involvement.

Had any alcohol or drugs been consumed in previous 12 hours by the driver?

Yes

Please give details of type and amount of alcohol or drugs consumed.

3. Insured Vehicle Details

Vehicle Make & Model

Year

Registration*

Vehicle Use

Private

Business

4. Loss Details

Date of Incident*

Time of Incident

Address where the accident occured

Where was the vehicle being driven?

Was the vehicle being driven with your consent?

Yes

How did the incident occur?*

Do you consider yourself responsible for the accident?

Yes

5. Damage to Insured Vehicle

Was your vehicle damaged?

Yes

Is your vehicle drivable?

Yes

Was your vehicle towed?

Yes

Have you obtained a repair quote?

Yes

Find the contact information of your preferred repairer and supplier.
https://www.qbe.com/au/3star/search#motor

Amount of quote $ (Please attach quote to bottom of form)

Where is your vehicle now?

Which panels were damaged?

Please attach photos at end of form if possible

Odometer reading if known

6. Damage to Other Vehicle(s)

Was another vehicle involved in the accident?

Yes

Other Driver’s Name

Address of Other Driver

Other Drivers Phone Number

Other Drivers Licence Number

Other Vehicle Make / Model

Other Vehicle Reg No.:

The other Insurance Company

Policy Number/Claim No.

Damage to other vehicle

Please attach photos if possible

Was a third vehicle involved in the accident.

Yes

Please give details of other vehicle(s)

7. Damage to Property

Did the accident cause any property damage?

Yes

Please describe property damage

2. Liability Claim Details

Date of the Incident*

Time of the Incident

Date you first became aware of incident

Please describe fully how the loss/damage occurred*

Address where the incident happened*

Are you the owner or occupier of the above address?

Owner/Occupier

Landlord

Tenant

If you lease the premises provide a signed copy of the Lease. (attach file below)

Has a claim been made against you?

Yes

Please provide details (copies of correspondence can be attached below)

Have there been prior incidents with similar circumstances?

Yes

Details of prior incident.

Do you consider yourself responsible for the accident?

Yes

State reason

Name and address of person(s) whom you consider to be responsible and their relationship to you.

Please provide details

3. Liability Property Damaged Details

Is the claim in relation to Property Damage?

Yes

Name of the owner(s) of the property damaged

Address

What is your relationship to the owner(s)?

Describe the details of damage

Property

Motor

Describe the property and the full details of damage

Make

Model

Year

Rego

Estimated cost of repair/replacement:

Was the property in your custody?

Yes

For what purpose?

Have any repairs been carried out?

Yes

Name of Repairer

Address of Repairer

Cost of repairs

4. Liability Injured Person(s) Details

Is the claim in relation to an injury?

Yes

Injured Persons Name

Injured Persons Address

Contact Phone Number

Details of Injuries

Relationship to Injured Person

Tick to add injuries to second person

Injured Persons Name

Injured Persons Address

Contact Phone Number

Details of Injuries

Relationship to Injured Person

2. The Property

DO YOU NEED EMERGENCY ASSISTANCE?

Yes

Was there any other insurance covering this damage current at the time of the occurrence?

Yes

Please give details.

Are the premises tenanted?

Yes

Please give details of tenant

3. Loss Details

Date of the Incident*

Time of the Incident*

Loss Street Address*

Loss Suburb*

Loss State*

Loss Postcode

How did the damage/loss occur?*

Who do you consider responsible for the damage?

Myself

Third Party

Unknown

Were the premises occupied at time of the loss?

Yes

Please give date when Last Occupied

4. Theft or Burglary

Was there theft or burglary?

Yes

How were the premises entered and where was the point of entry

Which parts of the premises were entered?

5. Damage to Building

Was there damage to the building?

Yes

Description

Name of repairer

Amount Claimed

Description

Name of repairer

Amount Claimed

Description

Name of repairer

Amount Claimed

Description

Name of repairer

Amount Claimed

Description

Name of repairer

Amount Claimed

Description

Name of repairer

Amount Claimed

Tick to add additional items

TOTAL CLAIMED

6. Loss or Damage to Contents

Was there Loss or Damage to Contents?

Yes

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

Tick to add additional items

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

Tick to add additional items

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

Tick to add additional items

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

Tick to add additional items

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

Tick to add additional items

Description of property

Where Purchased:

Date of Purchase

Value at Time:

Replacement Value:

TOTAL REPLACEMENT VALUE

ESTIMATE OF CLAIM

7. Glass Damage Details

Was there any glass damage?

Yes

What was broken?

Was the break through the entire thickness of the glass?

Yes

Please give details.

Has the break been repaired?

Yes

If yes, have you paid the account?

Yes

Was there damage to window signwriting?

Yes

Please give details.

Witness/Police Details

Was there a witness to the accident?

Yes

Witness Name

Independent witness or passenger?

Independent

Passenger

Contact details for witness

Was there a second witness to accident?

Yes

Witness Name

Was second witness independent or passenger?

Independent

Passenger

Contact details for second witness

Did a Police Officer take particulars?

Yes

Name/Station/Incident No.

Additional Information

Please include any additional information relating to your claim here.

ATTACH RELATED DOCUMENTS/PHOTOS

Please include photos of damage and quote for repairs

Attach Files (8 Files allowed. Max size per file is 4MB).

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 20 MB, Max. files: 12.

For large files please email to claims@abcountrywide.com.au

Contact Person Completing Form

Contact Name*

Contact Phone/Email*

Position in Company

1. Insured Details

2. Driver Details

3. Insured Vehicle Details

4. Loss Details

5. Damage to Insured Vehicle

6. Damage to Other Vehicle(s)

7. Damage to Property

2. Liability Claim Details

If you lease the premises provide a signed copy of the Lease. (attach file below)

3. Liability Property Damaged Details

4. Liability Injured Person(s) Details

2. The Property

3. Loss Details

4. Theft or Burglary

5. Damage to Building

6. Loss or Damage to Contents

7. Glass Damage Details

Witness/Police Details

Additional Information

ATTACH RELATED DOCUMENTS/PHOTOS

Contact Person Completing Form

ABOUT US

COMPLIANCE

SCORESBY HEAD OFFICE

DROUIN OFFICE

LEONGATHA OFFICE