Commercial Motor Vehicle Claim Form

VR. 1.2_02.16
Commercial Motor Vehicle Claim Form
IMPORTANT INFORMATION — PLEASE READ BEFORE COMPLETING THIS FORM
You have the right to seek access to your personal information and to
correct it at any time. For information about how you may access and
request correction of personal information we hold about you, or
complain about a breach of the Australian Privacy Principles, please
see our privacy policy available at www.gtins.com.au or contact us on
(02) 9966 8820 EST 9am-5pm, Monday-Friday.
Is someone making a claim against you?
Do not admit liability. You should request that any claim against you is
put in writing and you should provide all correspondence received
from the other party with this claim form. For further advice contact
your broker or contact GT Insurance on: (02) 9966 8820. Where
necessary, we will communicate with third parties and/or their insurer
on your behalf to establish the circumstances of the incident.
General Insurance Code of Practice
Your Excess
You will be advised of any excess(es) applicable to your claim. On
completion of repairs you may be required to pay the repairer the
amount of your excess together with any repair contributions. In some
instances you may be required to pay your excess to GT Insurance. If it
is determined by GT Insurance that the accident was not your fault we
will endeavour to recover any excess you have paid from the other
party.
Assessment & Repair of damaged vehicle(s)
After your claim has been reported to us we will arrange assessment of
your damaged vehicle(s). An experienced claims consultant will be
appointed to manage your claim.
Important Note: No repairs should be undertaken without the approval
of GT Insurance (with the exception of windscreen damage only).
Windscreen claims can be arranged directly through O’Brien Glass. O’
Brien Glass will contact GT Insurance to confirm the coverage
applicable to your vehicle. Please ensure you have your current policy
number and vehicle details available when you contact O’Brien Glass.
O’Brien Glass, 1800 645 011, www.obrienglass.com.au
Privacy Notice
The personal and sensitive information collected in this form, and
other information you or third parties provide in connection with this
insurance, will be used to provide and offer our products and services,
including the processing and settlement of claims, compiling and
analysing data, and resolving disputes. If you do not provide this
information to us we may not be able to provide these products and
services.
We may have to disclose your personal and other information to third
parties who assist us in providing our products and services, including
other insurers, intermediaries, health service providers, investigators,
assessors and loss adjustors, external insurance data collectors, our
advisors and service providers, related companies, dispute resolution,
statutory or regulatory bodies, or as required by law.
The Insurance council of Australia has produced the General Insurance
Code of Practice with the purpose of raising the standards of practice
and service in the general insurance industry. We support the
standards set out in the Code. A copy of this Code is available on our
website at www.gtins.com.au or from the Insurance Council of
Australia’s website at www.ica.com.au
Subrogation
You may prejudice your rights in relation to a claim made under
this policy if without prior agreement from us, you make an
agreement with a third party that will prevent us from recovering a
loss from that or another party.
Duty of Utmost Good Faith
Every insurance contract is subject to the duty of utmost good faith
which requires both the Insured and the Insurer to act towards each
other in utmost good faith. Failure to do so on the part of the Insured
may prejudice any claim made under the policy or the continuation of
insurance cover by the Insurer.
The Insurer
Allianz Australia Insurance Limited ABN 15 000 122 850 AFS Licence No.
234708 of 2 Market Street Sydney, NSW 2000
The Underwriting Agency
Global Transport & Automotive Insurance Solutions Pty Ltd (GT
Insurance); ABN 93 069 048 255; AFSL No. 240714, of Level 6, 55
Chandos Street, St Leonards, 1590, is an underwriting agency which
specialises in arranging insurance in respect of motor vehicles. GT
Insurance acts as an agent of the Insurer to market, solicit, offer,
arrange and administer the insurance and has a binding authority to
deal with or settle claims on their behalf.
Completing this Form/Questionnaire:
1. Please complete all sections in full and provide any requested attachments.
2. If more space is required when completing this form, please attach a separate sheet.
3. The use of the term "You"or "Your" in this form refers to an Insured and their subsidiary companies and other entities in which they
have a controlling interest.
4. The use of the term "We", "Us" or "Our" in this form refers to the Insurer and its Underwriting Agency.
5. It is important you provide us with the information we require to assist you with your claim. If you do not provide us with the
required information your assessment may be delayed or we may by unable the manage your claim.
6. The information you provide will be treated in accordance with our Privacy Policy & Procedures, available at www.gtins.com.au
7. Please return the fully completed form to your Insurance broker, Agent or return to GT Insurance.
8. This form may be completed electronically or it can be printed and completed in hand writing.
Important: If hand written, please use CAPITAL LETTERS etc etc.
Email: [email protected]
Fax: (02) 9966 8840
Mail: PO Box 507 St Leonards, NSW 1590
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Section 1:
Policyholder Details
GT Insurance issue commercial motor polices that typically begin with CPG or CMB.
For example: CPG12345678, CMB12345678
Policy number:
Insured name/s
Insured's ABN
Australian Business Number (11 digits)
Contact name/s
E-mail
Contact number
Unit
Street number
Street name
Post Code
Suburb
State
For your records, you may provide us with your
own reference for this claim e.g. No. or Division.
Your Claim Reference
If you are registered for GST and are eligible to claim an ITC for the item/s that you are making a claim on, please
insert the percentage of entitlement.
(ITC) entitlement%
Your Broker or Agent
Broker or Agent Claim
Reference No.
Insert if known
Has the Insured in the
past 5 years been:
Section 2:
(a) refused insurance or had an insurance policy cancelled
Yes
(b) convicted of any criminal offence?
No
Yes
No
Insured Vehicle Details
Please select the vehicle type Your claim relates to:
Passenger Vehicle
Plant & Equipment
Goods Carrying Vehicle
Sedan or Station Wagon
Earthmoving Plant
< 4.5 Tonnes GVM
Four Wheel Drive
Quarry/Mining Plant
4.5 – 8 Tonnes GVM
Van or Utility up
to 4.5 tonnes
Agricultural/Light Plant
Over 8 Tonnes GVM
Logging/Forestry
Prime Mover only
Bobcast/Skidsteer Loaders
Prime Mover & Trailer
Concrete Pumping Trucks & Drilling Rigs
Trailer only
Bus or Coach
Other
Other
Please provide the following details in relation to the damaged vehicle:
Year
Make
Model
Registration Number
Unregistered
Vehicle ID
Insert Vehicle Registration No. or tick unregistered
Type of load being carried
Weight (kg) of load being carried
Is the Insured the owner of the vehicle?
Yes
No
Was the vehicle being driven / operated
with the Insured's consent?
Yes
If "No", please provide
owners name:
If "No", please provide
details:
No
Is the vehicle financed?
Yes
Vehicle identification can include the following identifiers: VIN,
Chassis No., Serial No. or Engine No.
No
Unknown
If "Yes", please provide
name of Financier:
Purchase price $
Does this claim involve any additional trailer(s) not already disclosed within Section 2 above?
Yes
No
If "Yes", please also complete ADDENDUM — SECTION A (page 6)
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Section 3:
Driver Details
First name
Surname
/
Drivers Date of Birth
/
(dd/mm/yyyy)
Contact number
Unit
Street number
Street name
Post Code
Suburb
State
Relationship of the
driver to the Insured
Insured — Owner/Drive
Employee
Contract/Casual Driver
Relative
Other
Drivers Licence Number
Licence expiry date
/
/ 20
(dd/mm/yyyy)
Class of Licence
C — Car
HR — Heavy Rigid
R — Rider
HC — Heavy Combo
LR — Light Rigid
MC — Multi Combo
MR — Medium Rigid
Other
How long has the driver been licensed to drive this class of vehicle in Australia?
Has the driver's licence ever been cancelled or suspended?
Yes
Years
Months
No
If "Yes", please
provide details:
Did the driver of the vehicle undergo any Breathalyser, Blood, Urine or Drug Test?
Breathalyser Test
Yes
No
If "Yes", specify results
Blood Test
Yes
No
If "Yes", specify results
Urine Test
Yes
No
If "Yes", specify results
Drug Test
Yes
No
If "Yes", specify results
Section 4:
Claim Type
Please select the best description of the type of claim You wish to make:
A vehicle accident involving another vehicle(s) or other parties property
Windscreen or fixed glass breakage
Vehicle damage not involving any other vehicle(s) or property
Theft of Vehicle
Vehicle fire - other than a bush fire or as a result of an accident
Malicious Damage
Hail, Flood, Storm, Bush Fire or Cyclone damage to a vehicle
whilst not being driven
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Section 5:
Incident Details
Please provide details of the incident surrounding this claim:
/
Date the incident occurred
/ 20
(dd/mm/yyyy)
Time the incident occurred
Between
Location where the incident occurred
:
AM
PM
Unit
And
:
AM
PM
Street number
Street name
Post Code
Suburb
State
Select the relevant
conditions
Weather conditions
Road conditions
Situation
Dry
Tarmac / bitumen
Straight Road
Drive way
Wet
Gravel / dirt
Bend
Bridge
Raining
Sand / beach
Highway
Tunnel
Hailing
Intersection
Private Property
Flood
T — intersection
Car Park
Round About
Other
Estimated speed of your vehicle (km/h)
Estimated speed of other vehicle (km/h) if involved
Type of load being carried
Weight (kg)
Describe how the incident occurred
Name of the person last in charge of the vehicle
First name
Surname
Contact number
Did this incident result in damage to another person(s) vehicle(s) or property?
Yes
Section 6:
No
If "Yes", please also complete ADDENDUM — SECTION B (page 7)
Damage to Insured Vehicle
Describe the damage to the vehicle
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Was the vehicle towed from the scene?
Yes
No
Yes
No
Yes
No
If "Yes", please provide details
of tow company:
Has a repair quote been obtained?
Is the vehicle drivable?
Address where the vehicle can
be assessed:
If "Yes", please attach to this form
Unit
Amount $
Street number
Street name
Post Code
Suburb
State
Do you have a preferred repairer?
Yes
No
If "Yes", please provide
contact details of repairer:
If the vehicle was stolen, has it been recovered in a damage condition?
Yes
No
n/a
Would you like to provide photos of the damage to your vehicle?
Yes
Section 7:
If "Yes", please attach when returning this form
No
Police & Witness details
Was the incident reported to the police?
Yes
No
/ 20
/
If "Yes", please confirm the date
(dd/mm/yyyy)
Did the police attend the accident scene?
Yes
No
If "Yes, please provide the following:
Police event / report No.
Officer's name / number
Police Station
Police action taken or pending?
Yes
No
Were there any witnesses to
the accident?
Yes
No
If "Yes", please provide details:
Unknown
If "Yes, please provide the following:
Witness name and address
First name
Surname
Contact number
Unit
Street number
Street name
Post Code
State
Suburb
Section 8:
Addendum / Additional Attachments
Please indicate if this form will include any of the following upon submission:
Addendum A for Additional Trailers (You indicated in Section 2 that this claim involves additional trailers)
Addendum for Third Party Damage (You indicated in Section 5 that the incident involved damage to
another parties vehicle or property
Separate sheet detailing answers which you could not fit adequately on the form
Supporting documentation (e.g. repair quotes, photos)
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ADDENDUM — SECTION A:
Additional Trailers
This section is to be completed if you indicated in Section 2: Vehicle Details, that this claim involves additional trailers
No. of additional trailers involved in the incident:
Please provide details for each additional trailer. If more space is
required please provide details in a separate attachment.
Trailer 1
Trailer 2
Trailer details
Trailer details
Year
Make
Year
Make
Model
Model
Trailer type (e.g. logging, refrigerated)
Trailer type (e.g. logging, refrigerated)
Type of load being carried
Type of load being carried
Weight (kg) of load being carried
Weight (kg) of load being carried
Trailer Registration Number
Trailer Registration Number
Trailer Serial Number
Trailer Serial Number
Is the Insured the owner of the vehicle?
Yes
No
If "No", please provide owners name
Is the vehicle financed?
Yes
Is the Insured the owner of the vehicle?
Yes
No
If "No", please provide owners name
No
Unknown
Is the vehicle financed?
Yes
If "Yes", please provide name of Financier
If "Yes", please provide name of Financier
Purchase Price $
Purchase Price $
No
Unknown
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ADDENDUM — SECTION B:
Damage to Other parties vehicle(s) or property
This section is to be completed if you indicated in Section 5: Incident details, that the incident involved damage to another parties vehicle(s) or property
No. of Other parties vehicles(s) or properties damaged in
the incident
Please provide details for each additional vehicle/property damaged.
If more space is required provide details in a separate attachment.
Other party vehicle / property 1
Other party vehicle / property 2
Details of Other Vehicle
Details of Other Vehicle
Year
Rego
Year
Rego
Make
Make
Model
Model
Describe the damage to the Other Vehicle or Property
Describe the damage to the Other Vehicle or Property
Owners information
Owners information
First name
First name
Surname
Surname
Contact number
Contact number
Unit
Street number
Street
name
Street
name
Suburb
Suburb
Post Code
State
Street number
Unit
Post Code
State
Drivers information of the other Vehicle
(if different to the Owner)
Drivers information of the other Vehicle
(if different to the Owner)
First name
First name
Surname
Surname
Contact number
Contact number
Unit
Street number
Unit
Street
name
Street
name
Suburb
Suburb
Post Code
State
Post Code
Drivers Licence Number
Licence expiry date
Street number
State
Drivers Licence Number
/
/ 20
Licence expiry date
(dd/mm/yyyy)
/
/ 20
(dd/mm/yyyy)
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Section 9:
Declaration
Declaration
Completion of this declaration certifies that:
The information that You have given in this form is truthful, accurate and complete. No information likely to affect this claim
has been withheld.
You understand that this claim may be refused if information is untrue, inaccurate or concealed.
You have read and understand the Privacy Act 1998 information referred to above and consent to the collection, storage, use
and disclosure of personal and sensitive information of all
persons affected by this claim, with their approval.
If You do not agree to the collection of this personal and sensitive information, GT Insurance will be unable to process Your
claim.
You have either completed this form personally or, if it has been on Your behalf, You have checked that the questions have
been fully and accurately answered.
Do You agree?
Yes
Completed by:
First name
Surname
Date of declaration
/
/
(dd/mm/yyyy)
Global Transport & Automotive Insurance Solutions Pty Ltd
ABN 93 069 048 255; AFSL No. 240714
Sydney
Newcastle
Albury
Melbourne
02 9966 8820 02 4920 8698 02 6023 5308 03 8623 2666
Brisbane
Head Office: Level 6, 55 Chandos Street, St Leonards NSW 1590 Australia
PO Box 507 St Leonards, NSW 1590 Australia
Townsville
Darwin
Perth
Adelaide
07 3210 0666 07 4779 5178 08 8981 7510 08 9324 1963 08 8232 7645
Auckland
Christchurch
09 377 4143 03 421 8930
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