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Member Details
Fleet
Rego
Kilometre’s
Make
Model
Month & Year
Registered Owner Name
Mobile
Address
Suburb
Email
TAXI/RIDESHARE DRIVER DETAILS
First Name
Last Name
Address
Suburb
State
Postcode
Mobile
Driver Email
Licence Number
Licence Image (Front)
Licence Image (Back)
Expiry Date
Licence Years Held
Did the driver consumed any alcohol or taken any drugs in the 24 hours prior to the accident?
Yes
No
Please provide details
Did the driver undergo a breath test, breath analysis or blood test?
Yes
No
What was the reading
INCIDENT DETAILS
Date
Day
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Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Time
Number of vehicles involved
Street Name
Suburb
Nearest Crossroad
Road Surface
Dry
Wet
Loose
Storm/Flood
At the time of incident, the covered vehicle was
Moving
Stationary
Parked
Traffic Controls
None
Stop Sign
Traffic Lights
Roundabout
Give Way
Merge
Your Direction of Travel
North
South
East
West
Additional Information
Accident Location
Use Current Location
Vehicle Images (Max 10)
Maximum 10 images allowed. Supported formats: JPG, PNG, GIF
Vehicle 360° Video
Upload a short 360° walkaround video of the vehicle. Supported formats: MP4, MOV, WEBM
ACCIDENT DESCRIPTION - Describe how the accident happened
(if you need more space, attached a sheet of paper)
Estimate the speed of your vehicle: ____ km/hr
Estimate the speed of other vehicle: ____ km/hr
Description
Was your vehicle towed
Yes
No
Where is your vehicle now
Towed by
Towed to
OTHER VEHICLE DETAILS
Rego
Make & Model & Colour
Driver First Name
Driver Last Name
Owner details
Address
Suburb
State
Postcode
Mobile
Email
Cover Company Details
Claim Number
Is there any Passenger in Vehicle
Yes
No
Passenger Name
Passenger Mobile
Passenger Email
Passenger Address
Was anyone injured
Yes
No
If YES provide details
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POLICE INFORMATION
Was the accident reported to the police
Yes
No
Did the police attend the accident
Yes
No
Officer Name
Station
Event Number
WITNESS DETAILS
Name
Mobile
Address
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DISCLAIMER
DO YOU DECLARE THAT THE DETAILS YOU HAVE PROVIDED TO US ARE TRUE AND CORRECT AND NOT MISREPRESENTED IN ANYWAY?
Yes
No
DRIVER OVER THE AGE OF 21
Yes
No
CLAIM FORM SIGNED AND DATED BY DRIVER
Yes
No
COPY OF DRIVER LICENSE (FRONT & BACK) ATTACHED
Yes
No
Signature
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PRINT NAME
DATE
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