H2P CAR INSURANCE MOTOR ACCIDENT CLAIM FORM CLAIM NUMBER NAME OF CLAIMS OFFICER PHONE NUMBER IMPORTANT INFORMATION ABOUT MAKING A CLAIM 1. Please ensure PERSONAL INFORMATION is read before signing the DECLARATION. 2. Please answer, in full, all of the questions on this form and ensure that the DECLARATION is signed. Omission of relevant information may delay your claim or prevent us from allowing the claim 3. Where available, please provide supporting documentation in support of the amount claimed. 4. You may be required to produce proof of ownership of items for which you are claiming. Proof of ownership may be by way of valuations, photographs, receipts or accounts of purchase. 5. You must not carry out repairs, dispose of any damaged property, admit liability to anyone else, negotiate, pay or settle a claim with anyone else, without our consent. In the event of being approached by the other party or their representative, we ask you not to admit liability in any way. If you receive any correspondence relative to this matter, please forward it to us for our attention. 6. The aim of H2P Car Insurance is to provide you with efficient and speedy claims service and quality customer service. 7. The issue of this MOTOR CLAIM FORM is in no way, admission of liability by H2P CAR INSURANCE 1. INSURED PERSONAL DETAILS Policy Number Name of Insured Address (Private) Address (Business) Phone Number (Hm) (Wk) (Mb) (Email) Are you registered for GST? No Yes ABN Percentage of Input Tax Credit claimable (Please consult with your taxation adviser to ascertain the accurate percentage) Occupation 2. INSURED VEHICLE DETAILS Make of Car Model of Car Year of Manufacture Registration Number Engine Number / Vehicle Identification Number Colour If the vehicle is subject to finance arrangements, state the name of the company Account number 3. DATE & LOCATION DETAILS OF THE ACCIDENT / LOSS Day and date of the Accident Location of the Accident Time of the Accident Suburb / Town
4. DRIVER DETAILS Driver of the Insured Vehicle at the time of the accident Mr Mrs Miss Ms Other Family Name Given Names Address Phone Number (Hm) (Wk) (Mb) (Email) Does the driver hold a current Australian Driver s Licence? No Yes Class of Licence Date of Birth / / How long has this driver held the driver s licence (in years and months) Has the driver ever been refused insurance? No Yes If Yes give details Has the driver had any accidents, thefts, fires or other incidents involving a vehicle (whether an insurance claim was made or not) in the last 5 years? No Yes If Yes give details Has the driver had any traffic related charges / infringements, loss of licence, altered licence conditions or on the spot fines in the last 5 years? No Yes If Yes give details Does the driver own any other motor vehicle? No Yes If Yes what is the name of the insurer? Policy Number Registration Number Was this vehicle in use at the time of the accident? No Yes 5. VEHICLE USE Was the vehicle being used with the consent of the insured? No Yes For what purpose was it being used? Personal Use Business Use Was the vehicle towed from the scene? No Yes If Yes, by whom? Was the insured vehicle towing a trailer at the time of the accident? No Yes If Yes, please provide the name of the owner and insurance details
6. ALCOHOL & DRUGS Had the driver of the insured vehicle consumed any intoxicating liquor or drugs in the 12 hours prior to the accident? No Yes If Yes, how much and what type of liquor or drugs were consumed? When was the alcohol or drugs consumed? Was the driver of the insured vehicle taken to hospital? No Yes What is the name of the hospital the driver of the insured vehicle was taken to? If the driver of the insured vehicle was taken to hospital following the accident, the Blood Alcohol Certificate must be sent us. What was the result of the Blood Test? 7. POLICE Did Police attend the accident? No Yes If Yes, was an Alcohol Test or Breathalyser Test conducted? No Yes Result If the Police did not attend the accident, has the accident been reported to the Police? No Yes If Yes, what Police Station was the accident reported to? Date reported to the Police Time Police Report Number provided at the scene or upon reporting the accident to a Police Station. NOTE: All accidents where the total damage exceeds $1,000 or there is Bodily Injury must be reported to the Police within 24 hours of the accident. Has any police action been taken or threatened in connection with this accident? No Yes If Yes, please provide details of charges made or threatened 8. PASSENGERS Were there any passengers in the insured vehicle at the time of the accident? No Yes If Yes, please give names and addresses of all passengers and their relationship to the insured. 9. WITNESSES Were there any independent witnesses to the accident? No Yes If Yes, please give names, addresses and phone numbers of all independent witnesses.
10. IMMEDIATELY BEFORE THE ACCIDENT At what speed was the insured vehicle travelling (a) 20 metres before the accident (b) at impact Was your vehicle on the correct side of the road? No Yes If Yes how far from the left hand edge of the road? Were the headlights and taillights on? No Yes Did you give any warning? No Yes If Yes, what warning? What signal, if any did you give? What was the type of road surface? Was this surface wet or dry? What were the weather conditions? 11. INJURIES Were there any injuries as a result of the accident? No Yes If Yes, please provide details 12. OTHER VEHICLES / PROPERTY INVOLVED If more than one other vehicle was involved, please attach a separate sheet with the details requested in this section. Name of the other driver involved Address Phone Number Vehicle Details Registration Number Does any relationship exist between the insured and the other party? No Yes Describe the damage to the other vehicle / property Name of the insurer of the other vehicle, type of cover and policy number What was the approximate speed of the other vehicle immediately before the accident? What distance was the other vehicle from you (a) when first seen? (b) when danger became apparent? If there was no other vehicle involved, was there damage to someone else s property? No Yes If Yes, who is the owner of the damaged property? Please describe the damage to the other person s property
13. HOW THE ACCIDENT HAPPENED Please explain as clearly as possible, how the accident happened. (If there is insufficient space, please attach extra details) Please sketch the scene of the accident, showing all traffic lights and road signs. My Vehicle Pedestrian / Cyclist Other Vehicle Point of Impact Position of Witness N 14. DAMAGE TO THE INSURED VEHICLE Are you claiming for damage to the insured vehicle? No Yes If Yes, please describe the damage to your vehicle. Please mark, on the pictures below, the damage to your vehicle 15. REPAIRS Which repairer would you prefer to carry out repairs? (Note: we prefer you to use an RAA Approved crash repairer) Where is the vehicle now and under whose charge? Has a quote for repairs been completed? No Yes Quote Number What is the total quote for repairs? If a quote has not been done, what is the estimated repair cost? NOTE: Please ask your repairer to phone our claims department to arrange the assessment of your vehicle
ADDITIONAL INFORMATION (if required) PERSONAL INFORMATION The personal information you give us is used to assess the extent of (insurance) risk that you have proposed to us. It also plays part in determining fair and competitive premiums and as regards to claims, in particular, helps us determine your entitlement. If you do not want to provide the information we request, this can either delay or prevent us from providing the insurance cover you want or allowing a claim. As a normal part of our business activities, claims related information is provided to, and on occasions obtained from, Insurance Reference Services Ltd. This is a company independent of RAA Insurance, which collates and distributes claim data to and from other general insurers. Also, limited information is, at times, provided to other general insurers when confirming or seeking insurance related details involving claims or policy entitlements. If you wish to gain access to your personal information, that we hold in our records, please contact us on 8202 4393. Privacy of your information is important to us. We do not rent, sell or trade your information. We use your personal details to ensure our records are correct and in order so that we can provide you with the best possible service and products. From time to time, the RAA or one of its related companies may contact you sith some direct offers that may be of interest to you. Please contact us if you do not wish to receive direct offers from the RAA. DECLARATION The information and answers given in this form are truthful, accurate and frank. 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 authorise RAA Insurance to give or obtain, from other insurers, any insurance reference bureau or any other party, any information relating to this insurance or any other insurance held by me/us or any insurance claim made by me/us. WARNING: Wilful or reckless exaggeration or inflation of the amount claimed may forfeit the claim. Signature of Driver Date / / Signature of Insured Date / / Telephone 8202 4393 H2P Insurance Underwritten by RAA Insurance Limited ABN 14 007 872 602 AFS Licence No. 232525 GPO Box 1499 Adelaide SA 5001