Digital Claims Form - Claims Connect

Your Car

Driver

Driver's Title *

Driver's Name *

Driver's Email *

Driver's Address *

Driver's Suburb *

Driver's Postcode *

Driver's Phone (Personal) *

Driver's Phone (Business)

Car Owner

Car Owner's Title *

Car Owner's Name *

Car Owner's Email *

Car Owner's Address *

Car Owner's Suburb *

Car Owner's Postcode *

Car Owner's Phone (Personal) *

Car Owner's Phone (Business)

Repairer

Repairer Name *

Repairer Phone *

Insurance Details

Insurance Company Name *

Insurance Cover *

Comprehensive
Third Party
None

Vehicle Details

Driver's Vehicle Make *

Driver's Vehicle Model *

Driver's Vehicle Year *

Driver's Vehicle Reg No. *

Other Details

Hire Car Required? *

GST Registered? *

ITC%

ABN

Loss of Wages? *

Other Car

Other Driver

Other Driver's Title *

Other Driver's Name *

Other Driver's Email *

Other Driver's Address *

Other Driver's Suburb *

Other Driver's Postcode *

Other Driver's Phone (Personal) *

Other Driver's Phone (Business)

Other Car Owner

Other Car Owner's Title *

Other Car Owner's Name *

Other Car Owner's Email *

Other Car Owner's Address *

Other Car Owner's Suburb *

Other Car Owner's Postcode *

Other Car Owner's Phone (Personal) *

Other Car Owner's Phone (Business)

Other Driver's Insurance Details

Other Driver's Insurance Company *

Other Driver's Insurance Cover *

Comprehensive
Third Party
None

Other Vehicle Details

Other Car's Make *

Other Car's Model *

Other Car's Year *

Other Car's Reg No *

Additional Information

Place of Accident

Place of Accident - Street *

Place of Accident - Suburb *

Date & Time of Accident *

Detailed Description of Accident

Please provide a detailed description of the accident

Diagram of Accident

Use the key below to draw a diagram of the accident and then upload a photo here.

Diagram of Accident Upload *

Drop your file here or click here to upload

Injuries

Has the driver or any passengers been injured? *

Witnesses

Witness Name

Witness Address

Witness Phone

Police Report

Did Police Attend? *

Was the matter reported to the police? *

Police Report/Event Number

Date Incident Reported

Police Officer's Name

Station

Authorisation

1. I authorise Claims Connect to act on my behalf as an agent.

2. I authorise Claims Connect to send and receive documents such as invoices,quotes and reports in relation to this claim.

3. I authorise Claims Connect to arrange an assessor to substantiate my losses.

4. I authorise Claims Connect to retain a solicitor to act on my behalf if deemed necessary.

5. I acknowledge Claims Connect’s fees and authorise the deduction and payment of these fees once any losses are recovered.

6. I acknowledge that if I withdraw my claim without consent from Claims Connect, I will be responsible for all fees and disbursements.

7. I hereby irrevocably appoint Claims Connect as my agent for the purpose of conducting my claim, including but not limited to settling my claim without reference to me.

Signature

Melbourne | Sydney | Brisbane

P: 1800 965 111

info@claimsconnect.com.au