Non Fault Accident Replacement Vehicle - Application Form

It is important for you to try and fill this form out to the best of your ability in relation to the accident you have just had. We realise this may be a stressful time and if you prefer to speak to one of our specialists please call them on 1300 135 485.

Filling this form in should take no longer than 5 minutes provided you have all the information handy. Once we have these details we should be able to facilitate a vehicle to you a lot quicker. If you don’t have everything, don’t worry, just fill in what you can. Remember to call if you have any questions.

YOUR DETAILS

Title
First Name
Last Name
Address
Post Code
Home Phone
Work Phone
Mobile
Email
DOB
dd/MM/yyyy
Are you the Owner?help

PERSON AT FAULT

Title
First Name
Last Name
Address
Post Code
Home Phone
Work Phone
Mobile
Licence No.help
Is this person the Owner?help

VEHICLE DETAILS

Vehicle Rego No
Business/Private Use
Make
Model
Year of Carhelp

OTHER VEHICLE DETAILS

Vehicle Rego No.
Make
Model
Year of Car

INSURANCE DETAILS

Insurance Co.
Please Enter your Insurance Company name
Type of Coverhelp
Claim No.
Are you claiming on your policy or direct against the other parties?help

OTHER INSURANCE DETAILS

Insurance Co.
Please Enter your Insurance Company name
Type of Coverhelp
Claim No.

ACCIDENT DETAILS

Accident Details help:
Datehelp
Time
Street
Suburb
No of Cars Involved
Who Admitted Liability?help
Was it Verbally of Written?
Were there any witnesses?help
If so please provide information

OTHER INFORMATION

Location of Damagehelp
Is you car Driveable?help
Date Rental Vehicle Requiredhelp
Which repairer are you usinghelp
Est days to repairhelp  
Are you registered for GST?help
ABN Number
Did Police Attend scene?help
How did you hear about us?
Other:
Additional Information
Files Acceptable files: PDF,DOC,DOCX,GIF,PNG,JPG,JPEG. Max. size 1MB


Uploaded File(s):
Disclaimer: I understand and authorise that any data collected may be used to facilitate my application and I have reviewed the FAQs in relation to this process Click here to view our FAQs.