Motor Vehicle Claim Form - Sanderson Insurance

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1300 230 272

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Contact Name

Contact Phone No.

ABN No.

Policy No.

Vehicle finance company

Date of incident

Time of incident

Location

Description of incident

Road conditions

Sealed Unsealed Wet Dry Other

Other road conditions

Did police attend?

Yes No

Police event no.

Attending officer

Vehicle Make and Model

Rego No.

Damage to Vehicle

Location of Vehicle

Repairer's Name

Repairer's Phone No.

Name of Driver

Driver DOB

Licence Number

Licence Expiry

Years licenced

Did the driver drink any alcohol, take any drugs or medication in the 12 hours prior to the accident?

Yes No

If yes, what did the driver drink or what drugs or medication did the driver take?

In the past 5 years, has the policyholder or driver in this incident: * Had a driver’s licence cancelled, suspended, been disqualified from driving or committed any driving related alcohol or drug offences? * Had an insurance policy declined, cancelled or conditions imposed on an insurance policy? * Committed any criminal offence?

Yes No

If yes, state the details

Third Party Name

Third Party Address

Third Party Make/Model

Third Party Rego No.

Third Party Phone Number

Third Party Insurer

Your Bank Account No.

Your Bank Account Name

Your Bank Account BSB

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Contact

Phone

1300 230 272

Email

enquiry@sanderson-insurance.com.au

Address

Level 6, 384 Hunter St Newcastle

Services

Mobile and Tower Cranes
Earthmoving, Plant & Machinery Hire
Contract Works Insurance
Public and Product Liability
Professional Indemnity Insurance
Commercial Motor Vehicle & Fleet
Business & Property Owners
Management & Liability
Residential Property & Private Motor Vehicle
Other Insurance

Mobile and Tower Cranes
Earthmoving, Plant & Machinery Hire
Contract Works Insurance
Public and Product Liability
Professional Indemnity Insurance
Commercial Motor Vehicle & Fleet
Business & Property Owners
Management & Liability
Residential Property & Private Motor Vehicle
Other Insurance

General Advice Warning: Please be aware that any advice that may have been given or implied is general advice only. We have not taken into consideration your individual needs, objectives or financial requirements. Before deciding to purchase a financial product, you should consider the appropriate Product Disclosure Statement to ensure the product is suitable for your needs.

Sanderson ABN 60 134 400 883 Corporate Authorised Representative of Ausure Pty Ltd
ABN 94 096 971 854 AFS Lic. No. 238433

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