Make a claim Please select the type of policy you wish to make a claim against. Once completed, one of our claims team will get back to you as soon as possible. Please select a policy type*PersonalBusinessPlease select the claim type*Property ClaimMotor Vehicle ClaimMotor Vehicle ClaimInsured Name*Policy Number*Contact*Phone*Email* Registered for GSTYesNoInput Tax Credit entitlement on premium*Input Tax Credit entitlement on property damaged*Was the vehicle being used for*Business UsePrivate UseProperty Claim FormInsured Name*Policy Number*Contact*Phone*Email*Registered for GSTYesNoInput Tax Credit entitlement on premium*Input Tax Credit entitlement on property damaged*When did the loss, theft or damage occur?* Date Format: MM slash DD slash YYYY Time* : HH MM AMPM Which is:Occupied by the insuredUnoccupied / VacantA holiday homePlease describe what happened*Vehicle DetailsYear*Make*Rego*Model*Is there any finance owing on the vehicle?*YesNoAre you claiming damage for the vehicle?*YesNoDetailed description of the damageWas the vehicle towed?*YesNoHas a repair quote been obtained?*YesNoWhat is the current location of the vehicle?*Preferred repairer details*Incident DetailsDate:* Date Format: MM slash DD slash YYYY Time:* : HH MM AMPM Location (street/suburb)*Please describe what happened in the accident and why it occured. e.g. speed, traffic lights, weather:*Who does the driver consider is at fault and why?*Drivers DetailsName*Contact Phone*Date of Birth:* Date Format: MM slash DD slash YYYY Licence No*Expiry Date*Year Licensed*Licence TypeLearnersProbationaryFullClassDid the driver consume alcohol/drugs/medication in the 12 hours prior to the accident?*YesNoHad insurance declined, cancelled or special conditions imposed in the last 5 years?*YesNoConvicted of or had any fines or penalties imposed for any criminal offence?*YesNoHad an accident or made a claim on a motor insurance policy in the last 5 years?*YesNoIf YES to any of the above, please provide details*Third Party DetailsThird Party Details Name*Contact Phone*Address*Insurance Company*Policy/Claim No*Rego*Licence No*Year*Make*Model*Detailed description of the damage*Police Details (Name/Station/Police Report No.)Police Details (Name/Station/Police Report No.)*Witness DetailsWitness Details*Additional DetailsAdditional Information*Incident DetailsANY LOSS INVOLVING MALICIOUS DAMAGE, LOST OR STOLEN PROPERTY MUST BE REPORTED TO THE POLICEWere the premises occupied at time of loss?*YesNoIf no, date last occupied* Date Format: MM slash DD slash YYYY Time* : HH MM AMPM Do you know who is responsible for the loss, theft or damage?YesNoNameAddressPlease detail what has been lost/stolen/damaged and estimate value to repair/replaceParticularsAmount Claimed Fusion/Power Surge ClaimsAge of MotorIs the motor under warranty?YesNoBurglary ClaimHow was the building entered?Available security to premises:Give details of any security improvements taken since the loss:PoliceStationReport NumberDate Reported Date Format: MM slash DD slash YYYY Reporting OfficerIf your insurer approves a cash settlement, would you like funds deposited into your bank account?YesNoBankBSBAccount NameAccount NumberHistoryHad insurance declined, cancelled or special conditions imposed in the last 5 years?YesNoConvicted of or had any fines or penalties imposed for any criminal offence?YesNoHad an accident or made a claim on a motor insurance policy in the last 5 years?YesNoIf YES to any of the above, please provide detailsDeclarationDo you agree to the declarations* I agreeBy submission of this claim for, you acknowledge and accept the following DeclarationsPrivacy The Privacy Act and the Australian Privacy Principles require your insurer to tell you that they collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to Insurance Reference Services (IRS), etc. or other parties as required by law. By reading and acknowledging the Adroit privacy collection notice you consent for us to proceed with submitting this information to your insurer. You have to right to seek access to your personal information and to correct it at any time. Please contact us on (03) 5244 7813, 8:45am - 5:15pm, Mon-Fri and advise the changes.Declaration I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed. I/We acknowledge that I/We have read and understood the privacy information of all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then the Insurer will be unable to process my/our claim.