Motor Insurance Claim

Motor Insurance Claim Notification Form

Please note:

We are committed to managing your claim efficiently and keeping you informed every step of the way. Your claim will be handled by the Coverforce in-house claims team, however your Coverforce Marine broker will also be available to assist with any questions or guidance throughout the process.

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

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? *

YesNoUnsure

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 *

Time of Loss *

Loss Location

Driver Name *

Driver Date of Birth

Vehicle Registration Number *

Drivers Licence Number *

Drivers License Expiry *

How long have you held your driver’s licence (for the class of vehicle involved in this claim)?

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 *

Is there damage to the insured vehicle? *

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 driver 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

Additional comments

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