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New Claims Report - Motor Vehicle
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* Required information.
Date *
Time *
Insurance company & Policy Type *
Insured name and client code *
Contact Name *
Mobile Telephone Number
Other contact
ABN No and ITC %
Date and time of loss *
Situation of loss - Street *
Suburb *
Incident description *
Estimate: $ *
Police attend *
Report Number
Station & Officer Name
Vehicle Make and Registration *
Location of the Vehicle
Is the vehicle drivable *
Drivers Name *
Date of Birth *
Licence Number and Expiry Date *
Years licenced *
Alcohol/drugs in last 24 hours *
Breathalyser/blood test taken *
Third Party Details
Name *
Address *
Phone Numbers
Vehicle and Registration
Insurer
Claim form sent *
Repair quotes obtained *
I agree upon submission that the information provided is true and correct. *

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