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Cullclear Life

Home
About Us
Services
Resources
- Insurance Calculators
- Broker App
Blog
Contact
- Complaints
Call 1300 131 343
Get a Quote
Cullclear Life

Motor Vehicle Claims

The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged beforehand, no repairs or alterations to the damaged vehicle should be made unless approved by your insurance underwriter.
Policy Number:
Due Date:
Insured Details
Insured’s Name*
Address*
Postcode*
Phone No.*
Occupation
Email*
What is your Australian Business Number (ABN)?
Are you registered for GST?
- Yes
- No
To what extent are you entitled to claim an Input Tax Credit on the GST applicable to the premium?
Are you the sole owner of the insured vehicle?
- Yes
- No
If NO, who is the owner?
Insured Vehicle
Make & Model
Year
Rego Number*
Rego Expiry Date
Colour
Class of Vehicle
- Sedan or Station Wagon
- Van or Utility up to 2T
- Rigid Vehicle over 2T and up to 5T
- Rigid Vehicle over 5T and up to 10T
- Rigid Vehicle over 10T
- Articulated Prime Mover
- Bus or Coach
- Light Construction or Earthmoving Plant
- Heavy Construction or Earthmoving Plant
- Trailer
- Other
Trailer Details (if applicable)
Make
Type
Year
Registration No.
Driver
If the vehicle was unattended, who was responsible for the vehicle at the time of the loss.
Surname
Given Name(s)
Address
Postcode
Phone No.
Date of Birth
Gender
- Male
- Female
Driver Licence
Expiry Date
Years Held
Registered Owner of Vehicle
Are you an employee?
- Yes
- No
If not, state
Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years
- Yes
- No
If Yes, please give details including dates and circumstances.
Did you consume any alcohol or take drugs during the 12 hours prior to the accident?
- Yes
- No
If Yes, what was consumed, in what quantities and when consumed.
Did you undergo a breath test or blood test for alcohol or drugs?
- Yes
- No
If Yes, what was the result?
Did you refuse to undergo any of the above tests?
- Yes
- No
Damage to Insured Vehicles
Was your vehicle damaged?
- Yes
- No
Was your vehicle towed away?
- Yes
- No
Have you obtained a repair quote?
- Yes
- No
Repair quote amount $
(Attach Quote)
File
If you are unable to attach a quote, please advise the name of the repairer, their contact details and quote number.
Name of repairer
Contact details
Quote number
If not driveable, what is the full address where the vehicle can be inspected?
Phone No.
Describe in detail where the damages appear on your vehicle.
Accident Details
Business or private?
- Business
- Private
Date
Time
Vehicle Use:
What was the accident location?
Street
Suburb
P/Code
How did the accident happen?
Who do you consider was at fault?
- Myself
- Other Driver
- Something Else
Describe what / who else was at fault
Estimated speed of YOUR vehicle just before the accident
Estimated speed of OTHER vehicle just before the accident
What was the condition of the road?
- Sealed
- Unsealed
- Smooth
- Rough
- Wet
- Dry
How was visibility?
- Good
- Moderate
- Poor
Were there any witnesses to the accident?
- Yes
- No
If yes, please provide name/s, address/s and phone number/s.
Did Police attend the accident?
- Yes
- No
Police Station
Name/Number of Officer
If No, state time and date reported to Police
Did Police indicate who was responsible?
- Yes
- No
If Yes, Name of Driver
Did Police charge either driver or suggest action may be taken?
- Yes
- No
- Charge
Damage to Other Vehicle or Property
Vehicle or Property No. 1
Name of other driver:
Age:
Phone
Licence No:
Vehicle Make & Model:
Rego No:
Name of Registered Owner:
Address:
Phone
The Other Insurance Company:
Policy Number:
Description of Damage
Vehicle or Property No. 2
Name of other driver:
Age:
Phone
Licence No:
Vehicle Make & Model:
Rego No:
Name of Registered Owner:
Address:
Phone
The Other Insurance Company:
Policy Number:
Description of Damage
Personal Injuries
Was anyone injured in the accident?
- Yes
- No
Person A
Name
Type of Injury
Injured Party (Passenger/Driver)
Vehicle (Registration No.)
Person B
Name
Type of Injury
Injured Party (Passenger/Driver)
Vehicle (Registration No.)
How would you prefer us to contact you?*
- Phone
- Email
Comments
This field is for validation purposes and should be left unchanged.

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T/A Your Insurance Link

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ABN 26 988 418 405

Toll Free
1300 131 343

Taringa Office
Suite 101, 35 Morrow Street
Taringa QLD 4068

Postal Address
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Indooroopilly QLD 4068

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