Motor Insurance Claim

Motor Insurance Claim Notification Form

Simply fill out the claim notification form below and one of our claims specialists will be in contact with you shortly.

Fields marked with an * are required

Please indicate if you are the broker or the policy holder? *

BrokerPolicy Holder

Broker First Name *

Broker Last Name *

Broker Email *

Insured Client Code (WinBEAT or Insight) *

Insured's Details

First Name *

Last Name *

Insureds Address *

Street address *

City *

State *

Postcode *

Email Address *

Mobile Phone *

Policy Number *

Insured Person Name or Business Name

GST Registered? *

YesNo

ABN *

Input Tax Credit (ITC) Percentage *

Is the insured the preferred contact person?

YesNo

Contact Details

Preferred contact person if not the insured details provided above.

First Name

Last Name

Email Address

Mobile Number

Relationship to the insured

Claim Details

Date of Loss / Incident *

Loss Location

Time of Loss *

Vehicle Registration Number *

Driver Name

Driver Date of Birth *

Drivers Licence Number

Drivers Licence Class

How many years has the driver held a licence? *

Drivers License Expiry

Loss / Incident Details

Was there a third party involved? *

YesNo

Third Party Name

Third Party Address

Third Party Vehicle Registration

Third Party Phone

Third Party Insurer Name

Third Party Claim Number

Description of claim *

If your policy allows, would you like to nominate a repairer or use the insurers nominated repairer? *

Yes, the vehicle is damagedNo damage to the insured vehicle

If your policy allows, would you like to nominate a repairer or use the insurers nominated repairer?

I would like to nominate a repairer - if allowed.Use insurers nominated repairer

Nominated Repairer Business Name

Nominated Repairer Suburb

Supporting Documents / Files

Upload Supporting Documents or Files

Click here to upload files to substantiate your claim eg. police report, images, quotes, invoices, photos etc.

File Upload 1

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File Upload 2

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File Upload 3

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Do you have additional files to upload?

Yes No

File Upload 4

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File Upload 5

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File Upload 6

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Do you have additional files to upload? *

Yes No

File Upload 7

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File Upload 8

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File Upload 9

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Disclosure Questions (Please answer if applicable to claim)

Did the drive consume any alcohol or drugs during the 12 hours before the accident?

YesNo

Details *

Was the driver tested by the police for alcohol or drugs?

YesNo

Result *

In the past 5 years, has the driver

YesNo

a. Been charged with, or convicted of, or penalised for, any motoring offences? (This includes on the spot fines but does not include parking offences)

YesNo

b. Had a driving licence suspended, cancelled or restricted by endorsement?

YesNo

c. Been charged with or convicted of any criminal offence?

YesNo

d. Had any insurance policy cancelled or special conditions imposed?

YesNo

If you answered yes to any of the above, please provide details

Broker comments to claims staff

Additional comments

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