Motor Vehicle Accident Claim Notification

You can notify us with the details of your claim here.

Conditions of On-line Claim Notification

Acceptance of this form by Roderick Insurance Brokers Pty Ltd does not constitute acceptance or authorisation of the claim.

We will contact you within 48 business hours to advise you on how to proceed with your claim (normal business hours apply 9am - 5pm Monday - Friday)

Would you like to proceed with this claim notification form ? Yes No

Insured Name
Policy Number
Contact Details (Please supply contact details for this claim)
Contact Name
Contact Phone Number	Work Private Mobile STD Number Mobile
Contact Email Address
Vehicle Details
Registration Number
Name of Registered Owner
Year of Vehicle
Make
Model
Type of Body	Sedan Wagon Coupe Other
Do you owe money on this vehicle?	Yes No If Yes Lenders Name?
Is there any prior unrepaired damage on the vehicle?	Yes No If Yes where?
What were you using the vehicle for at the time of the accident?	Travelling to Work Shopping Business Use Other (Please describe)

Accident Details
Are you registered for GST Purposes?	Yes No

If Yes. What is your ABN?
When did the accident happen?
What time did the accident happen?
Where did the accident happen?
How did the accident happen? (Describe in detail the circumstances leading up to the accident and how the accident happened.Â It is important to be as accurate as you can)
Please tell us which driver you feel is at fault and why?
What were the road conditions at the time of the accident?	Sealed Roadway Wet Dry Unsealed Roadway Wet Dry
Where is the damage on your vehicle? Please list as per the numbers on diagram below
	Area 1 Area 2 Area 3 Area 4 Area 5 Area 6 Area 7 Area 8
As a result of the accident was there any other property damaged? (eg fences telephone poles etc)	Yes No If yes provide details
Where is the vehicle now?
Was it towed?	Yes No If yes by whom?
Has the tow invoice been paid?	Yes No If yes how much?
Driver Details
Who was driving the vehicle when the accident happened? Please provide drivers full name
Drivers date of birth
Drivers Address	Postcode
Drivers Phone Number
Drivers Licence Number & Expiry Date	Licence Number Expiry Date
Did the driver consume any alcohol, or take any drugs or medication in the 12 hours prior to the accident?	Yes No If yes provide details?
Other Driver Details
Please provide drivers full name
Drivers date of birth
Drivers Address	Postcode
Drivers Phone Number
Drivers Licence Number & Expiry Date	Licence Number Expiry Date
Registration Number
Name of Registered Owner
Year of Vehicle
Make
Model
Type of Body	Sedan Wagon Coupe Other

Witness Details
Full Name of Witness
Please provide an address for the witness	Postcode
Please provide phone number for the witness
Type of Witness	Passenger in insuredâ€™s vehicle Passenger in other vehicle Independent eye witness
Other Details
Did the police or fire brigade attend the accident?	Police Fire Brigade
Was the accident reported to the police?	Yes No If Yes Officers Name Name of Station Date Reported
Was either driver asked to take a blood / breathalyser test?	Yes No Insured Driver Result % Other Driver Result %
Was either driver charged with an offence or offences or advised that charges may be laid?	Insured Driver Other Driver Please list the offences

History
Have you or the driver of your vehicle had any insurance or renewal of insurance declined or special conditions imposed in the last 5 years?	Yes No If yes provide details?
Have you or the driver of your vehicle ever been charged or convicted with any criminal offence?	Yes No If yes provide details?
Have you or the driver of your vehicle suffered a loss or made a claim on a vehicle in the last 5 years?	Yes No If yes provide details?
Have you or the driver of your vehicle ever been charged or convicted of any motoring offence or been disqualified from driving in the past 5 years?	Yes No If yes provide details?
If Yes to any History Questions please give Details
Privacy
The Privacy Act 1988 requires us to tell you that as an insurance broker we collect your personal and sensitive information in order to calculate your loss and entitlements and handle claims. When handling claims we may have to disclose your personal and other information to third parties such as other insurers, loss adjusters, investigators and agents or other parties as required by law. You have the right to seek access to your personal information and to correct it at any time. Please contact us on (03) 5226 5999 EST 9am-5pm Mon - Fri and advise us of the changes.
Declaration
I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that the claim may be refused if the information is untrue, inaccurate or concealed. I/We acknowledge that I/we have read and understood the Privacy Act 1988 information referred to above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons affected by this claim. I/we acknowledge that if I/we do not agree to the collection of this personal and sensitive information that Roderick Insurance Brokers will be unable to process my/our claim.
I Agree	Yes No

Motor Vehicle Accident Claim Notification

Conditions of On-line Claim Notification

Contact Details

Vehicle Details

Accident Details

Driver Details

Other Driver Details

Other Details

History

Privacy

Declaration