Claim Form - Prestige Car Insurance for your Special Vehicle

Company

This field is for validation purposes and should be left unchanged.

Contact Name*

Contact Email*

Phone Number*

Brokerage

If you are a broker completing this claim form on behalf of an insured then please provide your brokerage name.

Email me a copy

Yes Please

Full Name of Policy Holder*

Policy Number

Are you registered for GST purposes?

Yes
No

% ITC Claimed

Please enter a number from 0 to 100.

What are you claiming for?

Accidental Damage
Glass Only
Theft

Driver Details

First Name	Last Name	DOB	Licence Number	Licence Expiry	Phone Number

Was the driver at fault?

Yes
No
Unsure

Was another party involved in this incident?

Yes
No

Were alcohol/drugs consumed by the driver in the 12 hours prior to the incident?

Yes
No

Vehicle Details

Vehicle Year	Vehicle Make	Vehicle Model	Vehicle Variant	Vehicle Registration	VIN

Preferred Repairer

Incident Date

Incident Time

:

Incident Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date Theft Discovered

Time Theft Discovered

:

Name of last person who used vehicle?

Address of last person to use the vehicle?

Who discovered the theft?

Has the vehicle been recovered?

Yes
No

When and by whom?

Details of damage to vehicle?

Vehicle Current Location

Was the required security device fitted and activated?

Yes
No

Location at time of theft

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reason vehicle was left at this location

Was the theft reported to the police?

Yes
No

Police Station

Police Report Number

Accident Cause

Hit Object
Hit Rear
Damaged Whilst Parked
Changing Lanes
Reversing
Lost Control
Malicious Damage
Fire
Natural Events

Description of Incident (State fully and clearly how accident occurred)

Other Party Driver

First Name	Last Name	Licence Number	Contact Phone Number

Other Party Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Party Vehicle Details

Vehicle Year	Vehicle Make	Vehicle Model	Vehicle Registration

Other Party Insurance Company

Other Party Insurance Policy Number

Were there any witnesses to incident?

Yes
No

Witness Details

First Name	Last Name	Contact Phone Number

File

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Max. file size: 2 MB.

I/We declare that the foregoing details are correct and not misrepresented in any way*

I accept

Signature*

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