Claims Connect

Claims Form

Your Car

Driver



Car Owner



Repairer



Insurance Details



Vehicle Details



Other Details



Other Car

Other Driver



Other Car Owner



Other Driver's Insurance Details



Other Vehicle Details



Additional Information

Place of Accident



Detailed Description of Accident



Diagram of Accident



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



Drop your file here or click here to upload

Injuries



Witnesses



Police Report



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.


Melbourne | Sydney | Brisbane

P: 1800 965 111

info@claimsconnect.com.au