Motor Vehicle Accident Claim Form

▲ indicates a required field

CLIENT DETAILS
▲ Policy number or CWT reference:
▲ Name on the policy:
▲ Contact person:
Home phone number:
Work/mobile number:
Email address:
Fax number:
▲ Postal address line 1:
Address line 2:
▲ Town/Suburb:
▲ State/Country:
▲ Postcode:
ACCIDENT DETAILS
▲ Date of accident (dd/mm/yyyy):
▲ Time of accident (am/pm):
▲ Where did the accident happen? Street
Town/Suburb   State
▲ Describe how the accident happened:
▲ Was anyone hurt? Yes  No
VEHICLE DAMAGE

Please check the relevant boxes to show damage to vehicle (use diagram to assist)

No vehicle damage
All panels damaged
Windscreen/window glass
Engine		 Interior
Undercarriage
Burnt
Stripped
1 Passenger Front
2 Driver Front
3 Driver Side
4 Driver Rear
5 Passenger Rear		 6 Passenger Side
7 Front End/Bonnet
8 Roof
9 Rear End
Was the vehicle towed? Yes  No
If yes, where was the vehicle towed to?
VEHICLE DETAILS
▲ Year:
▲ Make/model:
▲ Registration no:
▲ Body type:
DRIVER DETAILS
▲ Driver's name:
▲ Age:
▲ Was the driver the insured? Yes  No
▲ How long has the driver had their licence?
DRIVER HISTORY
Has the driver:
▲ Had any insurance declined or cancelled
or special conditions imposed in the last 5 years?		 Yes  No  (If yes, please provide details):
▲ Committed any criminal offence in the last 5 years? Yes  No  (If yes, please provide details):
▲ Had an accident or made a claim on a Motor Vehicle Insurance policy in the last 5 years? Yes  No  (If yes, please provide details):
▲ Had a Driver's Licence cancelled, suspended or restricted, or been disqualified from holding a Driver's Licence for any period in the last 5 years? Yes  No  (If yes, please provide details):
▲ Committed any driving-related or alcohol/drug-related offence in the last 5 years? Yes  No  (If yes, please provide details):
THIRD PARTY DETAILS
▲ Was anyone else's property or vehicle damaged/involved in the incident? Yes  No
If yes, please complete as many details as possible.
If no, continue to the next section.
What was damaged?
Vehicle make:
Model:
Registration:
Licence number:
Driver's name:
Owner's name:
Home number:
Mobile number:
Address:
Suburb/Town:
Insurance company:
Policy number:
Claim number:
POLICE
▲ Did the police attend the accident? Yes  No  (If yes, please provide details):
▲ Did the driver consume any alcohol or drugs during the 12 hours before the accident? Yes  No  (If yes, please provide details):
WITNESSES
▲ Were there any witnesses to the event? Yes  No
Witness name:
Home number:
Mobile number:
Address:
Suburb/Town:
Where were they at the time of the accident?
PRIVACY
As part of our claims service, we will record your claim lodgement from the details that you provide. 
▲ Please confirm that you are the Insured Person authorised to lodge this claim, or if not , please confirm that you have been appointed as the agent of the insured person and are authorised to lodge this claim. Yes  No
▲ With regard to our Privacy Policy, do you consent to the collection, storage, use and disclosure of personal information by Allianz for claims handling purposes? Yes  No
DECLARATION
▲ In addition we need to inform you of the importance of providing truthful and accurate information, please confirm you understand that this claim may be refused if the information is untrue, inaccurate or concealed? Yes  No

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