Where can the vehicle be inspected? (please state full address):
ARISTOCRAT
Aristocrat Reference MARSH Reference
Division Branch Centre Code
Telephone Number Sales Service Admin
Name of Custodian Vehicle
Surname
Given Names
Occupation
Work Telephone
Work Email
1. Aristocrat Driver Details
Title OtherMsMissMrsMr
Fax Number
Date of Birth
License Number Expiry Date
Have you ever been convicted of any traffic offence or had your license suspended? Yes No
If so, give details
Age
Was another person driving the vehicle at the time of the accident? Yes No
If so, was he/she driving with your consent? Yes No
Use of vehicle at time of accident/loss Business Private
2. Aristocrat Vehicle Details
Rego. Number Rego. Expiry Date
Vehicle Model
Vehicle Make
Damage to Aristocrat vehicle:
(indicate areas damaged after printing)
Yes
No
3. Third Party Details
Driver's Name
Driver's Address
Owner's Name
Owner's Address
License No.
MOTOR VEHICLE ACCIDENT REPORT & CLAIM FORMClaims Managment Services
MARSH Pty Ltd ACN 004 651 512 International Risk Consultants & Insurance Brokers
Vehicle Model
(indicate areas damaged after printing)
Date of Birth
Policy Number
Insurance Company Vehicle Make
Vehicle Year
Estimated Amount ($)
Estimated Amount ($)
Vehicle
Other Property
Description of Damage:
e-mail: [email protected] PO Box H176 Australia Square SYDNEY NSW 1215 Tel: (02)8864 8300 Fax: (02) 8864 8081
Company
Vehicle Rego. No.
Have you obtained a repair quote? (if yes, please attach)
Vehicle Year
4. Accident Details
Date of Accident
Time of Accident Place of Accident
Town of Accident
Accident Date/Location:
PMAM
Vehicle Speeds:
Aristocrat Vehicle km/h
Other Vehicle km/h
Conditions:
Weather Conditions
Road Conditions
e.g. (Sunny, Overcast, Raining or Otherwise)
e.g. (Wet, Dry, Rough or Otherwise)
Accident Description:
Accident Sketch: (complete after printing in the space below) Symbols For Sketch
(please show the names of streets)
Your Vehicle
Other Vehicle(s)
Person(s)
Traffic Lights
Stop Signs
Give Way Signs
5. Witnesses
Were there any witnesses to the accident? Yes No
Witness No. 1 Name
Address
Address
Witness No. 2 Name
Other VehicleYour VehicleIndependentType of Witness
Other VehicleYour VehicleIndependentType of Witness
Note: Passengers in Aristocrat vehicle provide phone contact, other witnesses, please attach details)
6. Police
Were the police advised of the accident? Yes No
If Yes, did the police attend the accident? Yes No
Officer's Name
Police Officer's Details:
Police StationOfficer's No.
Has either driver been charged? Yes No
If yes, what was the result?Were you required to undergo a breath test? Yes No
If yes, name
Offence(s)
7. DeclarationI/We understand that this claim may be refused if information is untrue, inaccurate or concealed.
Have you answered all questions? Yes No
Driver's SignatureHave you attached all required enclosures? Yes No
Today's Date
:
Paper form submissions may be made via one of the following means:
Email: [email protected] Fax: (02) 9725 5460
Post: 27 Britton Street, Smithfield NSW 2164
Recommended
