AssureUs Accident Claim Form

1

Review Details

These details are shown first so the customer can confirm what AssureUs already has on file.

Claim number Prefilled Claim form date Prefilled Full name Prefilled Company name Prefilled Contact number Prefilled Email Prefilled Street address Prefilled

State Prefilled Postcode Prefilled

Details that need correction

2

Your Vehicle

Vehicle details for the claim assessment.

State of registration Prefilled Registration number Prefilled Make Prefilled Model Prefilled Year Prefilled VIN number Prefilled

Current condition of your vehicle Upload clear photos of the vehicle and damaged areas. Registration certificate Upload the certificate as an image or supported media file.

3

Where did the event occur?

Core facts about the event location, timing, and how it happened.

Location Details

Use the closest known location details even if the exact event point is uncertain.

Date of event Use the calendar picker. Generated outputs display this as 01 Jan 1970 style. Time of event Uses Australia/Melbourne time in 24-hour format. Street at which accident happened

Search and select either a full address or a street name to fill suburb, state, and postcode. If any intersection

Search and select either a full address or a street name to fill suburb, state, and postcode for the intersection. Was the event caused by a failure or breakdown of your vehicle?

Notes

Driver's statement of how the accident occurred

Your vehicle speed Other vehicle speed

Who do you believe was responsible for the accident, and why?

Did anyone admit responsibility for the accident, verbally or otherwise?

Accident sketch Upload a photo of a clear sketch showing the event layout.

4

Driver Details

Details for the driver or person in charge of your vehicle.

Driver's name Date of birth Select a date from 01 Jan 1900 up to today. Driver address

Search and select a full address to fill the driver address, state, and postcode. Contact number Email State of licence Licence number Number of years licence held

Have you had any traffic charges or motor offence convictions in the past 5 years?

Have you made any motor insurance claims in the past 5 years?

Driver licence, front and back Upload both sides of the driver's licence.

5

Other Party

Add details for each other party involved, if known.

How many other parties were involved?

6

Witnesses

Add details for each witness, if any were present.

How many witnesses were present?

7

Police Details

Police report information, if a record was made.

Did a police officer make a record of the facts?

8

Vehicle Status

Towing, drivability, and inspection details.

Was the vehicle towed? Is the vehicle drivable?

9

Uploads

Review the files already added throughout the form and upload any extra supporting files here.

Uploaded files review Files added in earlier sections will appear here.

Additional files Extra claim photos, audio, or video.

10

Declaration

Final declaration and signature.

By submitting this claim form, I declare that all information provided is true, accurate, and complete to the best of my knowledge. I understand that claims cannot be processed unless all mandatory fields are completed and the required supporting documents are attached. Where an excess applies, no repairs or reimbursements will proceed until the applicable excess has been paid in full. Providing false, misleading, or incomplete information may result in the delay, denial, or cancellation of my claim.

Driver signature

Accident Claim Form

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