PRIVATE, FARM AND BUSINESS VEHICLE CLAIM FORM WARNING: Failure to supply true, complete or correct information may result in Your claim being declined. OFFICE USE ONLY Claim no: Policy no: Due date: / / Policy excess $: To allow Us to settle Your claim as quickly and efficiently as possible please supply: 1. A fully completed Claim Form. Please ensure full details of the third party are supplied (if applicable). 2. A copy of Your current Private, Farm or Business Vehicle registration papers (not applicable for windscreen claims). 3. A copy of driver s licence for driver of Private, Farm or Business Vehicle at the time of accident. 4. A quote and images of the damages via a reputable repairer are required. 5. You must complete Sections 1 to 3 inclusive, Section 14, read Section 13 and: a) if claim relates to Private, Farm or Business Vehicle been involved in an accident then please complete Sections 4 to 10 inclusive; or b) if claim relates to theft only, then please complete Section 11; or c) if claim relates to windscreen damage only, then please complete Section 12. Once You have returned this information We will appoint an assessor (if required) and take action as necessary. SECTION 1: DETAILS OF INSURED 1. Full name: 2. Full address: Telephone no. Business: Private: Mobile: Fax: Email: Preferred method of communication (tick one): Phone: Mobile: Fax: Email: 3. Occupation: 4. Business address: 5. Have any of the repairs been paid for? Yes No If Yes, please indicate on the account that payment has been made. SECTION 2: GST DETAILS 1. Are You registered for GST purposes? Yes No If Yes, what is Your ABN? 2. Have You claimed an Input Tax Credit (ITC) on the GST applicable to this policy? Yes No If Yes, what is Your ITC percentage for this policy? 100% or % If You are uncertain of Your ITC, Your accountant may be able to assist. SECTION 3: PRIVATE, FARM OR BUSINESS VEHICLE Year: Make: Model: Reg No: 1. Do You have any finance on this Private, Farm or Business Vehicle or other interested party? Yes No Give details of loan/finance/mortgage agreement, etc: 2. Give details of any modifications from the maker s standard specifications: 3. Registration current to: / / Issued by: Please attach a copy of registration papers to the Claim Form. 1
SECTION 4: TO BE COMPLETED BY THE INSURED 1. Date of accident: / / Time of accident: am/pm 2. State exact place of accident, including address and on whose property the accident occurred: Town, and Region: 3. State precise purpose for which Private, Farm or Business Vehicle was being used at time of accident: Was Private, Farm or Business Vehicle engaged in (tick one): Private Business Own Farming Contracting activities a) Give details of type of business or contracting undertaken: 4. Road condition (tick one): Sealed Metal/Tar Wet Dry Other Other: 5. Describe fully how the accident happened: 6. What was the speed of Your Private, Farm or Business Vehicle prior to braking before the accident? 7. What signal did You give? 8. What signal did the other driver give? 9. What lights on Your Private, Farm or Business Vehicle were operating? a) Were any Private, Farm or Business Vehicle lights known to be faulty? Yes No 10. Do You think that the other driver caused or contributed to the accident? Yes No If Yes, in what way? 11. Names and addresses of passengers in the Private, Farm or Business Vehicle at the time of the accident: Name Address Telephone 2
SECTION 5: DRIVER OR PERSON IN CHARGE OF THE PRIVATE, FARM OR BUSINESS VEHICLE AT TIME OF ACCIDENT To be completed whether Insured driving or not 1. Full name: 2. Date of birth: 3. Postal address: Telephone no. Business: 4. What type of driver s licence held? (tick one) Private: Learner Provisional Full Number Date of issue Date of expiry Classes covered How long held? Yrs Mths 5. Has the driver, during the past five years: a) Been charged and/or convicted of a traffic offence? Yes No If Yes, provide full details (each offence, year occurred, action taken): b) Had licence endorsed, suspended or cancelled? Yes No If Yes, provide full details (year occurred, nature of charge): If suspended, please provide the suspension period: c) Been involved in any previous vehicle accidents? Yes No If Yes, provide full details: 6. Does the driver suffer from any defect of hearing or other physical infirmity? Yes No If Yes, provide full details: 7. Did the driver consume any drugs (illicit or prescribed) or intoxicating liquor during 12 hours prior to the accident? Yes No If Yes, please state precise quantity and type: 8. Was a breath and/or blood test taken or requested? Yes No Reading results: 9. Was a trailer/caravan being towed? Yes No 10. IF DRIVER OTHER THAN INSURED: a) Do You own a vehicle? Yes No If Yes, who is the insurer? b) Relationship to Insured: c) Were You driving with the Insured s permission? Yes No 3
SECTION 6: DAMAGE (OWN VEHICLE) 1. Description of damage: 2. Where is the Private, Farm or Business Vehicle to be repaired? Estimate for repairs: 3. Where is the Private, Farm or Business Vehicle now? Is Your Private, Farm or Business Vehicle mobile? Yes No Is the Private, Farm or Business Vehicle in a remote area? Yes No NOTE: REPAIRS MAY NOT BE INITIATED WITHOUT INSURER S PRIOR CONSENT SECTION 7: DAMAGE (OTHER VEHICLES AND PROPERTY) 1. Name and address of owner of the other vehicle: 2. Name and address of driver of the other vehicle: 3. Registration number and make of the other vehicle: 4. Phone/contact number for owner/driver of other vehicle: 5. Name and address of insurers of the other vehicle: 6. Details of damage of the other vehicle: 7. Details of damage to other property: 8. Name and address of owner of other property: 9. Has any claim been made against You? Yes No SECTION 8: POLICE FORCE 1. Was the accident reported to police? Yes No If Yes, where and when? 2. If known, state name and/or number of police officer: Event no: 3. Is there any possibility that any person will be charged as a result of this accident? Yes No If Yes, whom? 4
SECTION 9: SKETCH OF ACCIDENT Please draw sketches showing position of Your Private, Farm or Business Vehicle and other vehicles and path of travel. It is important to detail all road signs, markings, distances, street names and direction of travel. N Give way Own Private, Farm or Business Vehicle Third party Stop SECTION 10: INDEPENDENT WITNESSES Name Address Telephone 5
SECTION 11: THEFT CLAIMS 1. Date and time theft was discovered: Date: / / Time: am/pm 2. Details of who last used the Private, Farm or Business Vehicle & their address/contact details: 3. Details of events leading up to theft: 4. Who discovered the theft? 5. Has the Private, Farm or Business Vehicle been recovered? Yes No If Yes, when & by who? 6. Was the Private, Farm or Business Vehicle locked? Yes No 7. Was the security alarm activated? Yes No 8. What type of system was it? 9. Location and time of the theft, please state reason the Private, Farm or Business Vehicle was in this location: 10. How did the driver travel home after discovering the theft? 11. Was the theft reported to police (provide officers name, police station)? 12. Provide details of damage: SECTION 12: WINDSCREEN BREAKAGE 1. Date of breakage: / / Location of breakage: 2. Describe how breakage occurred: 3. Type of damage (tick one): Shattered Bull s-eye type Cracked 4. Date new windscreen fitted by repairer: Date / / 5. Type of windscreen (tick one): Laminated Plain Full Tint Banded Tint 6. Name of repairer who fitted windscreen: 7. Address of repairer: 8. Has repair account been paid? (please attach repair account) Yes No 6
SECTION 13: PRIVACY NOTICE In this Privacy Notice the use of We, Us or Our means Inter Hannover and ARGIS, unless specified otherwise. We are committed to the safe and careful use of Your personal information in the manner required by the Privacy Act 1988 (Cth) and the Australian Privacy Principles and the terms of the PDS. We collect Your personal information in order to assess Your application for insurance and, if Your application is accepted, to administer and manage Your insurance policy and respond to any claim that You make. To do this, Your personal information may need to be disclosed to reinsurers and service providers and related entities who carry out activities on Our behalf, such as assessors and facilitators, some of whom may be located in overseas countries. Our contractual arrangements generally include an obligation for these reinsurers, service providers and related entities to comply with Australian privacy laws. By providing Us with Your personal information, You consent to the disclosure of Your personal information to reinsurers, service providers and related entities in overseas countries to enable Us to assess Your application, to administer and manage Your insurance policy and to respond to any claim that You make. If You consent to the disclosure of Your personal information to overseas recipients, and the overseas recipient handles Your personal information in a way other than in accordance with the Australian privacy laws, We may not be responsible for the handling of Your personal information by the overseas recipient. If You choose not to provide Your personal information and/or choose not to consent and/or withdraw Your consent to the disclosure of Your personal information to overseas entities at any stage, We may not be able to assess Your application or administer and manage Your insurance policy and respond to any claim that You make. Our privacy policies contain information on how You may access personal information that each of us hold, or seek correction of Your personal information and information on how to make a complaint about the handling of Your personal information and how complaints are handled. If You require more information, You can access Inter Hannover s Privacy Policy and Privacy Statement at www.inter-hannover.com/218887/inter-hannover-in-australia and ARGIS Privacy Policy at www.argis.com.au. SECTION 14: DECLARATION 1. Is there any other insurance policy in force in respect of Your Private, Farm or Business Vehicle? Yes No If Yes, please describe: 2. Have You or Your driver ever had a proposal or policy of motor vehicle insurance withdrawn, declined or cancelled? Yes No If Yes, please describe: I/We declare the information provided in this claim form to be true, complete and correct. I/We have read and understood the Privacy Notice above and consent to the collection, storage, use and disclosure of personal and sensitive information of all persons covered by this Claim Form. Where personal information has been provided on someone else s behalf, that person has consented to this provision. Signature of Insured: Date: / / Signature of driver: Date: / / If Your claim is accepted and a cash payment is made: If You would like Your settlement to be banked directly into your account, please provide the following details: Account name: BSB number: Account number: PLEASE RETURN TO: ARGIS - Claims Department Phone: 1300 032 733 Email: ARGISMotorClaims@inter-hannover.com Insurer: International Insurance Company of Hannover SE - Australian Branch (ABN 58 129 395 544, AFSL 458776) ( Inter Hannover ) SGUAS Pty Ltd t/as ARGIS Insurance (ABN 15 096 726 895, AFSL 234437) ( ARGIS ) issues policies for and on behalf of Inter Hannover. ARGIS acts under a binding authority given to it by Inter Hannover to administer and issue policies, alterations and renewals and in doing so ARGIS acts as an agent for Inter Hannover. ARGIS Private, Farm and Business Vehicle Claim Form - ARGIS IHAB PFBV CF 0517 7