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To discuss your claim by call: 1300 921 116 9am-6pm Monday to Friday

Alternatively submit your claim to us online by completing the application below and a member of our team will call you back to discuss your options during office hours.

Your Details

First Name

Last Name

Address

Mobile Phone

Date of birth

Your Licence Details

Licence number

State / Country

Licence expiry

Car Details

Make

Model

Car Year

Registration number

Vehicle Registered for

Are you the owner of the car?

At Fault Details

First Name

Last Name

Address

Mobile Phone

Date of birth

At Fault License

Licence number

State / Country

Licence expiry

Insurance Company

Type of cover

Claim Number

At Fault Car Details

Make

Model

Car Year

Registration number

Vehicle Registered for

Number of vehicles involved

Accident Information

Accident details / damage description

Accident Date

Accident Time

Accident Location

Address

Accident Damage

Witness & Police details

Witness name

Witness phone

Police Contact Name

Police Phone

Police Event Number

Declaration

I confirm that, to the best of my knowledge, the information I have provided is true, complete and correct.

I have read, understand and agree to the Privacy Policy which contains information about how you can access and correct your personal information, how to make a complaint, and how we deal.

I have read and understood the Agreement and Authority to Act & Terms and Conditions of Use.

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