Motor Vehicle Accident Report

Please complete this report as soon as possible after the accident. You can add photos, quotes and police details as you go. We will lodge the claim with your insurer and keep you updated.

Insured name (business or person) *Please answer this one.

ABNIf the insured is a business.An ABN has 11 digits.

Contact person *Please answer this one.

Phone *Please enter a phone number.

Email *We send your copy of the report here.Please enter an email address.

Are you registered for GST? *Please choose an answer.

YearPlease answer this one.

Make and model *Please answer this one.

Registration no. *Please answer this one.

StatePlease choose an answer.

VIN / chassis no.Please answer this one.

Use at time of accident *Please choose an answer.

Financed or leased? *Please choose an answer.

Financier namePlease answer this one.

Can the vehicle be driven? *Please choose an answer.

Where is the vehicle now? (address)Please answer this one.

Full name *Please answer this one.

Date of birthPlease answer this one.

PhonePlease enter a phone number.

Residential addressPlease answer this one.

Licence numberPlease answer this one.

StatePlease choose an answer.

Licence class/typePlease answer this one.

Years licensedPlease answer this one.

Relationship to insured (e.g. employee)Please answer this one.

Was the driver affected by alcohol or drugs? *Please choose an answer.

Had the driver's licence been suspended or cancelled in the last 5 years? *Please choose an answer.

Any other accidents or claims involving this driver in the last 3 years? If yes, give detailsPlease answer this one.

Date *Please answer this one.

TimePlease answer this one.

Location (street, suburb, nearest cross street) *Please answer this one.

WeatherPlease answer this one.

Road surfacePlease answer this one.

LightingPlease answer this one.

Describe what happened, in order *Please answer this one.

Sketch of the accident (show roads, direction of travel, vehicles marked A = your vehicle, B = other vehicle, and any signs or signals)

Optional. Draw with your finger or mouse, or upload a photo of a hand-drawn sketch.

Or upload a photo of a sketch:

Please answer this one.

Who do you believe was at fault? *Please choose an answer.

Did anyone admit fault at the scene? *Please choose an answer.

Describe the damage *Please answer this one.

Preferred repairer (if any)Please answer this one.

Was any property other than a vehicle damaged? (e.g. fence, building) *Please choose an answer.

Photos of all damage, the scene and the other vehicleOptional, but it speeds up the claim. Take photos now or choose them from your phone.

Repair quotes (if any)Optional.

Was another vehicle or party involved? *Please choose an answer.

Other party A

Driver namePlease answer this one.

PhonePlease enter a phone number.

EmailPlease enter an email address.

AddressPlease answer this one.

Vehicle make and modelPlease answer this one.

Registration no.Please answer this one.

Owner (if not the driver)Please answer this one.

Their insurerPlease answer this one.

Damage to their vehicle or propertyPlease answer this one.

Was there another party (Other party B)?Please choose an answer.

Other party B

Driver namePlease answer this one.

PhonePlease enter a phone number.

EmailPlease enter an email address.

AddressPlease answer this one.

Vehicle make and modelPlease answer this one.

Registration no.Please answer this one.

Owner (if not the driver)Please answer this one.

Their insurerPlease answer this one.

Damage to their vehicle or propertyPlease answer this one.

Were there any witnesses? *Please choose an answer.

Witness 1 namePlease answer this one.

PhonePlease enter a phone number.

AddressPlease answer this one.

Was there a second witness?Please choose an answer.

Witness 2 namePlease answer this one.

PhonePlease enter a phone number.

AddressPlease answer this one.

Were police called or the accident reported? *Please choose an answer.

Police stationPlease answer this one.

Officer namePlease answer this one.

Report / event no.Please answer this one.

Police report or event details (if you have them)Optional.

Was anyone injured? *Please choose an answer.

If yes, who was injured and how (and were they taken to hospital)? *Please answer this one.

I declare that the information in this report is true and complete to the best of my knowledge. I understand that giving false or misleading information, or leaving out relevant facts, may affect the claim. I authorise Insuregroup to give this report and any supporting documents to my insurer and others involved in assessing the claim, and to act on my behalf in lodging it.

Do not admit liability or agree to pay for the other party's damage without speaking to Insuregroup or your insurer first.

I agree with the declaration above *Please tick the box to continue.

Signature *Please sign in the box, or choose "Type my name" and type it.

Full name *Please answer this one.

Position (if signing for a business)Please answer this one.

Date *Please answer this one.

Insure Group Pty Ltd ABN 72 600 750 721 is a Corporate Authorised Representative (AR No. 464715) of Metrix Connect Pty Ltd ABN 23 635 286 136, AFSL No. 525491. hello@insuregroup.com.au