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Truck vehicle claims form

Policy holder
Full Name*
Address of Policyholder*
Street Address City State Postcode Country
Occupation*
Telephone Numbers
Business Hours After Hours
Insurer
Policy No
Expiry Date
DD slash MM slash YYYY
For what purpose was the vehicle being used?
Insured Vehicle
Make & Model*
Body Type*
Year of Manufacture*
Registration No*
Engine No
V.I.N. No
Expiry Date of Registration
DD slash MM slash YYYY
Name & Address of Finance Co. (if applicable)
Have there been any engine, body or transmission modifications from the manufacturer’s original specifications or any accessories added?*
- Yes
- No
If yes, please give details:
Driver (Please complete these details in respect of the person in charge of the vehicle at the time of the accident)
Full Name*
Address of Driver*
Street Address City State Postcode Country
Drivers Licence No*
State of issue*
How long has the driver held a motor vehicle drivers licence?*
Years
Expiry Date of Licence
DD slash MM slash YYYY
Was the vehicle being used with the full knowledge and consent of the policyholder?*
- Yes
- No
What is the relationship of the Driver to the Policyholder?
- Self
- Relative
- Employee
- Friend
- Other
If Other, please describe
Have you (the Policyholder) or the driver of the vehicle at the time of the accident
been involved in any previous motor vehicle accident in the last 5 years?*
- Yes
- No
been charged with any offence in relation to the use of a motor vehicle in the last 5 years?*
- Yes
- No
had any insurance declined or cancelled, been refused renewal of an insurance or had special terms imposed in the last 5 years?*
- Yes
- No
If “Yes”, to above, please give details below:*
More Details
Name Date Particulars (eg, name of insurance company, details of charges etc
Was the driver under the influence of any drug or alcohol at the time of the accident?*
- Yes
- No
Please state what drugs or how much alcohol was consumed by the driver in the 12 hours prior to the accident*
Did the driver undergo a breath test?*
- Yes
- No
If Yes, what was the reading?
Has the driver’s motor vehicle licence been cancelled or suspended in the last 5 years?*
- Yes
- No
If Yes, please give details
Accident Date
Date of accident*
DD slash MM slash YYYY
Time of accident

: Hours

Minutes

AM/PM
Description of Accident
Name of street where accident occurred
If at an intersection, names of intersecting streets
Suburb, Town, City
State clearly and fully how the accident occurred
Was the street wet?*
- Yes
- No
Did the other party admit liability?*
- Yes
- No
If Yes, please give details
Did the driver suffer any injury?*
- Yes
- No
If Yes, was medical attention required?*
- Yes
- No
If Yes, state name and address of doctor or hospital
Please indicate Insured Vehicle’s speed immediately prior to accident*
- Stationary
- Under 30 km/h
- 30-60km/h
- 60-80km/h
- 80-100km/h
- Over 100km/h
Please indicate Other Vehicle’s speed immediately prior to accident*
- Stationary
- Under 30 km/h
- 30-60km/h
- 60-80km/h
- 80-100km/h
- Over 100km/h
Was the vehicle towed from scene of accident?*
- Yes
- No
If Yes, please give name of towing contractor
Did you authorise this towing?*
- Yes
- No
Where can the vehicle be inspected?
(If at a repairer’s premises - name & address of repairer)
Telephone Number
Estimated Cost of Repairs (including parts)
Repair Quotation No
Please upload areas of damage to insured vehicle
Drop files here or

Max. file size: 2 MB.
Police
Date reported to Police
DD slash MM slash YYYY
Time reported to Police

: Hours

Minutes

AM/PM
Did the Police attend the accident?*
- Yes
- No
If Yes, please state
Name of driver charged or cautioned
Nature of charge or caution
This field is hidden when viewing the form
Question set finish
Other Parties
(Please complete this section if any other vehicles or property involved)
Number of other vehicles involved
Owner’s name and address
Number of other vehicles involved
Age
Make and Model of Vehicle
Registration Number
Driver’s name and address
Please give particulars of damage to other party’s vehicle and/or property
(If more than one third party involved, please provide similar particulars)
Witnesses
Passengers in Insured Vehicle
Names Addresses
Independent Witnesses
Names Addresses
ABN Details
Are you a registered business?*
- Yes
- No
What is your ABN No.?
What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?
Declaration
The information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld. I authorise my Insurer to undertake on my behalf whatever actions are necessary to indemnify me within the terms of my policy including if necessary, removal of my vehicle to alternative premises to enable repairs to be carried out by a qualified Motor Body Repairer. I understand that this claim may be refused if information is untrue, inaccurate or concealed.

I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Tudor Insurance Australia (Insurance Brokers) Pty Ltd in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”.
Driver’s Signature*
Date
DD slash MM slash YYYY
Policyholder’s Signature*
Date
DD slash MM slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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Melbourne Office

5/46-50 Old Princes Highway, Beaconsfield, VIC 3807, Australia

T: (03) 9707 3033

Noosa Office

Noosa Central, Unit 13, 6 Bottlebrush Avenue, Noosa Heads 4567

T: (07) 5228 3474
T: Emergency After Hours Phone 0419 500 301
F: (03) 9707 4568
E: service@tudorinsurance.com.au

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