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Your Details
First Name
Street Address
Suburb
Post Code
Email
Phone
Work Phone
Mobile
Date Of Birth
Insurance Details
Company Insured
Cover Type
Claim Number
Are you lodging claim through your own insurer or directly against the other party
Accident Details
Time Of Accident
Date Of Accident
Number of Vechicles Involved
Street/Suburb where the Accident took place?
Any Witnesses? If Yes provide thier details
Did anybody admitted the Liability
Did the Police visited accident site?
Any additional information that might help your claim?
Detail of your Vehilcle
Make/Model of your Vechicle
Your Plate Number
Manufacturing Year of your Car
Is your Car registered for GST Purposes? If Yes provide ABN number
Party at Fault Details
First Name
Street Address
Suburb
Post Code
Email
Phone
Work Phone
Mobile
License Number
Date Of Birth
Other Party's Insurance Details
Insured With
Cover Type
Claim Number
Repair Details
Date when the repair is starting?
Name of the Repairer?
Total number of days estimated for repairs
Describe the damage on vehicles?
Can your car still be driven?
Referrals
We can refer you to a compensation lawyer? Do you want us to contact you for that?
Other Party's Vehicle Details
Make/Model of your Vehicle?
Model
Plate/Rego Number
Does this person own the Car?
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