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Cullclear Life
Home
About Us
Our Company
Meet The Team
The Steadfast Difference
Associations
Careers
Financial Services Guide
Privacy Policy
Services
Insurance Advice
Specialty Schemes
Trainers Combined Liability Application
Professional Organisers Application
Travel Insurance
Premium Funding
Claims Management
Online Claims Forms
Payment
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
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