KLN Motor Fleet Claim Form

Facebook

This field is for validation purposes and should be left unchanged.

Post Title

1. Insured Details

Policy Number

Insurer

Insured Name

Reference Number

Insured's Address

Insured's Email*

Insured's Phone Number*

Select State*

Select Branch

Select State*

Select Branch in ACT*

Select Branch in NSW*

Select Branch in NT*

Select Branch in NZ*

Select Branch in QLD*

Select Branch in SA*

Branch in TAS*

Select Branch in VIC*

Select Branch in WA*

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

Name of Finance Company

Please attach stock card end of form.

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?*

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.

KLN Motor Fleet Claim Form

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

Group Administration Only

ABOUT US

COMPLIANCE

SCORESBY HEAD OFFICE

DROUIN OFFICE

LEONGATHA OFFICE