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Online Claim Form - Motor Vehicle

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Lodge your Claim Online

We have made it easier for clients to give all information accurately so that we can open up your compensation claim efficiently. This form is for any incidents on the road involved with motor vehicles.

By submitting your online claim, you agree to the Privacy Policy which can be found here.

Personal Details
Accident Details 1
Accident Details 2
Injuries and Employment
Declaration

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

Date Of Birth

Date of Birth

Interpreter

Language

Date and Time

Date

Time

Your Vehicle Details

Registration Number

Description of your vehicle

Name of the Owner of the Vehicle

Address of the Owner

Vehicle at Fault Details

Registration Number

Description of their vehicle

Name of Driver of their vehicle

Address of Driver

Phone Number of Driver

Other Vehicles Involved

Details of Other Vehicles (if there are none, say not applicable)

Location of the Accident

Location

Description of the Accident

Describe how the accident happened

Did Police Attend the Accident

Please Select

If so, what is the Event Number, otherwise please call (131 444)

Did you attend Hospital

Please Select

If so, which Hospital

Your Treating Doctor

Doctor’s Name

Address of Doctor’s Practice

What injuries have you sustained as a result of the incident?

Injuries sustained

What are your continuing disabilities

Disabilities

Where were you working at the time of the incident

Address of workplace

What is your weekly net income?

Income

How long have you been off work since the incident

Time

Have you returned to work

Please select

Have you had any prior injuries or claims

Please select

Please confirm that you have read the Privacy Policy

Please tick

Yes

Please confirm that all information you have given in the claim form must be true and correct in every respect

Please tick

Yes

Online Claim Form - Motor Vehicle

stay connected

Lodge your Claim Online

Personal Details

Accident Details 1

Accident Details 2

Injuries and Employment

Declaration

Name

Surname

Given Name(s)

Address

Home Address

Postal Address

Contact Methods

Contact Number

Email Address

Date Of Birth

Date of Birth

Interpreter

Language

Date and Time

Date

Time

Your Vehicle Details

Registration Number

Description of your vehicle

Name of the Owner of the Vehicle

Address of the Owner

Vehicle at Fault Details

Registration Number

Description of their vehicle

Name of Driver of their vehicle

Address of Driver

Phone Number of Driver

Other Vehicles Involved

Details of Other Vehicles (if there are none, say not applicable)

Location of the Accident

Location

Description of the Accident

Describe how the accident happened

Did Police Attend the Accident

Please Select

If so, what is the Event Number, otherwise please call (131 444)

Did you attend Hospital

Please Select

If so, which Hospital

Your Treating Doctor

Doctor’s Name

Address of Doctor’s Practice

What injuries have you sustained as a result of the incident?

Injuries sustained

What are your continuing disabilities

Disabilities

Where were you working at the time of the incident

Address of workplace

What is your weekly net income?

Income

How long have you been off work since the incident

Time

Have you returned to work

Please select

Have you had any prior injuries or claims

Please select

Please confirm that you have read the Privacy Policy

Please tick

Please confirm that all information you have given in the claim form must be true and correct in every respect

Please tick

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