Policy holderFull Name*Address of Policyholder* Street Address City State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Occupation*Telephone NumbersBusiness HoursAfter HoursInsurerPolicy NoExpiry Date DD slash MM slash YYYY For what purpose was the vehicle being used?Insured VehicleMake & Model*Body Type*Year of Manufacture*Registration No*Engine NoV.I.N. NoExpiry Date of Registration DD slash MM slash YYYY Name & Address of Finance Co. (if applicable)Have there been any engine, body or transmission modifications from the manufacturer’s original specifications or any accessories added?* Yes No If yes, please give details:Driver (Please complete these details in respect of the person in charge of the vehicle at the time of the accident)Full Name*Address of Driver* Street Address City State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Drivers Licence No*State of issue*How long has the driver held a motor vehicle drivers licence?*YearsExpiry Date of Licence DD slash MM slash YYYY Was the vehicle being used with the full knowledge and consent of the policyholder?* Yes No What is the relationship of the Driver to the Policyholder? Self Relative Employee Friend Other If Other, please describeHave you (the Policyholder) or the driver of the vehicle at the time of the accidentbeen involved in any previous motor vehicle accident in the last 5 years?* Yes No been charged with any offence in relation to the use of a motor vehicle in the last 5 years?* Yes No had any insurance declined or cancelled, been refused renewal of an insurance or had special terms imposed in the last 5 years?* Yes No If “Yes”, to above, please give details below:*More DetailsNameDateParticulars (eg, name of insurance company, details of charges etc Was the driver under the influence of any drug or alcohol at the time of the accident?* Yes No Please state what drugs or how much alcohol was consumed by the driver in the 12 hours prior to the accident*Did the driver undergo a breath test?* Yes No If Yes, what was the reading?Has the driver’s motor vehicle licence been cancelled or suspended in the last 5 years?* Yes No If Yes, please give detailsAccident DateDate of accident* DD slash MM slash YYYY Time of accident : Hours Minutes AM PM AM/PM Description of AccidentName of street where accident occurredIf at an intersection, names of intersecting streetsSuburb, Town, CityState clearly and fully how the accident occurredWas the street wet?* Yes No Did the other party admit liability?* Yes No If Yes, please give detailsDid the driver suffer any injury?* Yes No If Yes, was medical attention required?* Yes No If Yes, state name and address of doctor or hospitalPlease indicate Insured Vehicle’s speed immediately prior to accident* Stationary Under 30 km/h 30-60km/h 60-80km/h 80-100km/h Over 100km/h Please indicate Other Vehicle’s speed immediately prior to accident* Stationary Under 30 km/h 30-60km/h 60-80km/h 80-100km/h Over 100km/h Was the vehicle towed from scene of accident?* Yes No If Yes, please give name of towing contractorDid you authorise this towing?* Yes No Where can the vehicle be inspected?(If at a repairer’s premises - name & address of repairer) Telephone NumberEstimated Cost of Repairs (including parts)Repair Quotation NoPlease upload areas of damage to insured vehicle Drop files here or Select files Max. file size: 72 MB. PoliceDate reported to Police DD slash MM slash YYYY Time reported to Police : Hours Minutes AM PM AM/PM Did the Police attend the accident?* Yes No If Yes, please stateName of driver charged or cautionedNature of charge or cautionThis field is hidden when viewing the formQuestion set finishOther Parties(Please complete this section if any other vehicles or property involved)Number of other vehicles involvedOwner’s name and addressNumber of other vehicles involvedAgeMake and Model of VehicleRegistration NumberDriver’s name and addressPlease give particulars of damage to other party’s vehicle and/or property(If more than one third party involved, please provide similar particulars)WitnessesPassengers in Insured VehicleNamesAddresses Independent WitnessesNamesAddresses ABN DetailsAre you a registered business?* Yes No What is your ABN No.?What percentage of GST in your premium did you claim as an Input Tax Credit for the period of insurance in which this loss occurred?DeclarationThe information and answers given above are a true and complete statement of the facts and matters relating to the happening for which this claim is made, and no information likely to affect this claim has been withheld. I authorise my Insurer to undertake on my behalf whatever actions are necessary to indemnify me within the terms of my policy including if necessary, removal of my vehicle to alternative premises to enable repairs to be carried out by a qualified Motor Body Repairer. I understand that this claim may be refused if information is untrue, inaccurate or concealed. I expressly agree that the information given by me is provided with my full knowledge and consent and further agree to hold harmless and indemnify Tudor Insurance Australia (Insurance Brokers) Pty Ltd in the event of any action or matter that may be taken by any party pursuant to the Privacy Act 1988 (Cth). I/We acknowledge that I/we have read and understood the paragraphs accompanying this proposal headed “Your Privacy”. Driver’s Signature*Date DD slash MM slash YYYY Policyholder’s Signature*Date DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.
