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Insurance Claim FormGT Insurance Policy CPG20206919
Last Updated: 18/08/2020Page 1 of 2Alliance Leasing
Email completed claim form along with any other supporting documentation to jake.lee@gtins.com.au(Claims Consultant, GT Insurance)
Contact name
Contact Details Mobile
Date of Incident
Time of Incident
Location of Incident
Vehicle details Make/Model Rego
Year VIN
If you have photos of your vehicle and/or the third party vehicle, please email with this claim form
Current location of your vehicle
Do you have dashcam footage of the incident
Describe damage to your vehicle
Your vehicle-Driver details
Name DOB
Licence Number Number of years licensed
Licence Class Is the licencecurrent?
Alcohol or Drugs Were drugs or alcohol consumed in the previous 12 hours?
Breathalyser / Blood test taken:
Police Did police attend the incident?
Police Report Number
Insurance Claim FormGT Insurance Policy CPG20206919
Insurance Claim FormGT Insurance Policy CPG20206919
Third Party Details
Name of Owner
Name of Driver
Address of Driver
Make/Model
Rego Number
Third party vehicle insurer
Describe damage to third party vehicle/property
**Full incident Description Required**Detailed Incident description
Diagram
Last Updated: 18/08/2020Page 2 of 2Alliance Leasing
* Please save and download this form if completing itwithin the web browser to use the Submit Form Button. Alternatively you may save the completed form and email it directly to jake.lee@gtins.com.au.
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