JOHNS LYNG 1 - abcountrywide

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Post Title

Staff Completed

Admin Completed

1. Insured Details

Policy Number

Insurer

Insured Name

Reference Number

Insured's Address

Insured's Email*

Insured's Phone Number*

Select State/Business*

Select Name

Select Business in ACT*

Select Business in NSW*

Select Business in NT*

Select Business in NZ*

Select Business in QLD*

Select Business in SA*

Business in TAS*

Select Business in VIC*

Select Business in WA*

Select Steamatic Business*

Select Unitech Business*

Business Name*

What is your Australian Business Number (ABN)?

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

Please give details of conviction or involvement.

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

3. Insured Vehicle Details

Vehicle Make & Model

Year

Registration/Stock Number*

VIN Number

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

Please select preferred repairer. (ACT)

Please select preferred repairer. (NSW)

Please select preferred repairer. (NT)

Please select preferred repairer. (NZ)

Please select preferred repairer. (QLD)

Please select preferred repairer. (SA)

Please select preferred repairer. (TAS)

Please select preferred repairer. (VIC)

Please select preferred repairer. (WA)

Please supply details of Other repairer

Where is your vehicle now?

Odometer reading if known

4. Loss Details

Date of Accident*

Loss location

How did the accident happen? (max characters 3000)*

Please describe other purpose of vehicle use

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

Please give details of other vehicle(s)

5. Damage to Property

Please describe property damage

6. Witness/Police Details

Witness Name

Contact details for witness

Witness Name

Contact details for second witness

Name/Station/Incident No.

7. 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 (Total size of all files is 40mb maximum).

Drop files here or

Accepted file types: jpg, gif, png, pdf, jpeg, Max. file size: 10 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

By submitting this form you agree to Austbrokers Countrywide collecting my personal information in line with their Privacy Policy.

Johns Lyng Group
Motor Fleet Claim Form (FOR DRIVER)

1. Insured Details

2. Driver Details

3. Insured Vehicle Details

4. Loss Details

5. Damage to Property

6. Witness/Police Details

7. Additional Information

ATTACH RELATED DOCUMENTS/PHOTOS

Contact Person Completing Form

Johns Lyng Group Administration Only

ABOUT US

COMPLIANCE

SCORESBY HEAD OFFICE

DROUIN OFFICE

LEONGATHA OFFICE

Johns Lyng GroupMotor Fleet Claim Form (FOR DRIVER)

1. Insured Details

2. Driver Details

3. Insured Vehicle Details

4. Loss Details

5. Damage to Property

6. Witness/Police Details

7. Additional Information

ATTACH RELATED DOCUMENTS/PHOTOS

Contact Person Completing Form

Johns Lyng Group Administration Only

ABOUT US

COMPLIANCE

SCORESBY HEAD OFFICE

DROUIN OFFICE

LEONGATHA OFFICE

Johns Lyng Group
Motor Fleet Claim Form (FOR DRIVER)