Motor Vehicle
Accident Claim form
Complaints procedureEnthusiast Underwriting Pty Ltd is a member of the Financial Ombudsman Service. This independent service is provided to the insuring public at no cost and aims to resolve claims complaints quickly and informally. In the unlikely event of a complaint arising, you should contact your local Enthusiast manager on 1300 679 888. In most cases the problem will be resolved easily. If you are not satisfied with the response given by your local enthusiast manager you may contact our Enthusiast Internal Dispute Resolution Committee for advice and assistance in resolving your claim. You may also wish to direct your concerns to the Company Secretary & General Counsel of Assetinsure Pty Ltd on (02)9251 8055 orcomplaints@assetinsure.com.au. If you remain not satisfied with a decision made by our Internal Dispute Resolution Committee, the matter may be referred to the Financial Ombudsman Services for their independent ruling, provided the matter falls within their jurisdiction.
Financial Ombudsman Service Phone: 1300 780 808
Post: GPO Box 3, MELBOURNE Victoria 3001 Website:www.fos.org.au
Email:info@fos.org.au
Privacy
We respect your privacy and we comply with the Privacy Act and National Privacy Principles. A copy of Our Privacy Statement is available from any of our offices or online at www.enthusiast.com.au
Enthusiast Claims
PO Box 257
FERNY HILLS QLD 4055
Enthusiast Underwriting Pty. Ltd. ABN 35 142 206 746
1300 679 888
www.enthusiast.com.au
For prompt claims service this form must be returned to Enthusiast Underwriting, will all questions answered. Please print your answers and tick where appropriate.
Office use only Claim number
1. Policy Holder Details
Name/Business name Policy Number
Address State Postcode
Phone Work Phone: Work Phone: Mobile Fax Number
2. Insured Vehicle
Registration Number Year of Manufacture Make Model
Body type Odometer Reading Expiry date of Registration
Was there any unrepaired damage prior to the incident? Yes No
When was the vehicle purchased? (year) Amount paid
Is the vehicle under finance? Yes No Name of finance company Amount outstanding
For what purpose was the vehicle being used at the time of the collision?
Was any other insurance (other than Compulsory Third Party Insurance) in force on the vehicle at the time of the collision Yes No If yes state the name of the insurance company
/ /
$
$
3. Person in charge of the vehicle at the time of loss
Name Date of Birth
Address Phone Number
Licence Number of Driver Date Issued Expiry Date
Has the driver or insured had a policy cancelled, declined or higher excesses imposed in the past 5 years? Yes No if yes, please give details
Has the driver been convicted of any traffic offence in the past 5 years? Yes No if yes, please give details
Has the driver had their licence suspended in the past 5 years? Yes No if yes, please give details
Has the driver consumed any Alcohol, drugs or Medication that day? Yes No If yes, how long before the accident?
Type of Alcohol, Drugs or Medication Quantity consumed
Has the driver made a claim in respect to a motor vehicle in the past 5 years? Yes No If yes list details below
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How did the accident happen? Describe in detail the circumstances leading up to and including the collision. It is important to be accurate. Do not hide facts or circumstances which may not be in your favour. Please print clearly.
Please draw a diagram showing street, position of vehicles, direction of travel etc. Show North by arrow Symbols Your vehicle Other vehicle(s) Lane arrows Stop sign Street intersection Give way sign Curved street
Traffic light 4. The Accident
Day Date Time
When did the Accident Happen? Where did the accident happen?
The road conditions at the time? Sealed Road Wet Dry Unsealed Road Wet Dry
The Weather conditions at the time? Fine Overcast Rain Storm Hail
The Lighting at the time? Day Night Dawn Dusk
Estimated speed at the point of collision. a. Your Vehicle b. The other vehicle Did any driver admit fault? Yes No If yes who did?
/ / am/pm
5. Damage to the Insured Vehicle
Describe the damage to your vehicle directly resulting from this collision.
On the Diagrams below show the point of imp
Is the vehicle driveable? Yes No Was it towed from the accident scene? Yes If Enthusiast Underwriting needs to inspect the vehicle, please provide details of the contact person. Name
Address of vehicle Your Vehicle
6. Details of other vehicle and/or property
Owners name Address
Insurance Company
Drivers name (if not insured)
Address
Drivers Licence Number Expiry date Vehicle details
Year Make
Details of property if not a vehicle (if space insufficient attach a separate sheet)
/ /
Describe the damage to your vehicle directly resulting from this collision.
mpact by an X and the damaged areas by shading
Is the vehicle driveable? Yes No Was it towed from the accident scene? Yes inspect the vehicle, please provide details of the contact person.
State Other Vehicle
Details of other vehicle and/or property
Phone number
State Postcode
Policy number
Phone number
State Postcode
Drivers Licence Number Expiry date
Model
Details of property if not a vehicle (if space insufficient attach a separate sheet)
/ /
Is the vehicle driveable? Yes No Was it towed from the accident scene? Yes No
inspect the vehicle, please provide details of the contact person.
Phone number Postcode
Postcode
Postcode
7. Witnesses
Were there any witnesses to the collision? Yes No
1. Name Address State Postcode
Phone – Home Phone – Work Phone – Mobile
Type of Witness Passenger in your vehicle Passenger in other vehicle Independent eye witness
2. Name Address State Postcode
Phone – Home Phone – Work Phone – Mobile
Type of Witness Passenger in your vehicle Passenger in other vehicle Independent eye witness
8. Police (Please attach the police report to this claim form)
Were the police advised of the accident? Yes No Did the police attend Yes No
Which police station was the accident reported? Date?
Police Report Number. Was any driver charged with an offence? Yes No
Please give details below
If a Breath analysis was conducted what were the results (please attach a copy)
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9. Goods and services Tax(To ensure you not incur any unnecessary GST liabilities on this claim complete these details) Are you registered for GST purposes Yes No What is your ABN
If you have registered and have an ABN, have you claimed or will you be claiming an input tax credit on the GST applicable to this policy Yes No
Is the amount claimed less than 100% of the GST applicable to the premium. Yes No What is the percentage % 10. Electronic Funds Transfer(Settlement of your claim may involve a cash settlement. Please complete the following id you require an EFT payment)
Account name BSB number Account Number
11. I declare all the information I have given is true and correct
Signature of insured Date