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Motor Vehicle Accident Claim form

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Motor Vehicle

Accident Claim form

Complaints procedure

Enthusiast 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

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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

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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

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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)

/ /

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

References

Related documents

Other Vehicle(s) Details Owners Details: Name Phone No's Address Postcode Insurance Company. Make, Model & Body Type Year

I/We authorise The Insurer or its agent to give to and obtain from other insurers, insurance reference bureaus and credit reporting agencies any information relating to the

Your no claim discount will not be affected provided you are able to prove that some person other than you or the driver of the insured vehicle was totally responsible

(a) This claim form collects personal information about you (e) The collection of this information is required pursuant to the terms of your insurance policy; (b) The information

Make/Model Registration No. Has the driver had any other accident, loss or claim in connection with any vehicle during the past five years? YES/NO If Yes, please give details.

• If the other party involved in the accident has stated that you are being held responsible for the damage to the other vehicle or property, you should indicate that you will

Commence legal proceedings in my name to recover the cost of repairs and/or loss and damage to my vehicle, and any other losses including hire car costs and/or loss of income, for

I consent to Mutual Community General Insurance Pty Ltd using my personal information I have provided on this form for the purpose of processing my claim. I understand that if I