Quick and Easy Insurance Claims Form

Policy Details

Policy number

Best Contact Person (if not the insured, relationship to claim)(Required)

Email

Phone(Required)

Are you registered to GST for this claim?

Yes

No

ABN number

Do you intend to claim any Input tax Credit (ITC) on the GST applicable to this policy?(Required)

Yes

No

Specify percentage claimed

Incident Details

Date of incident(Required)

Time of Loss

:

Where did the incident occur?(Required)

Street Address Address Line 2 City State Post Code

Incident description(Required)

Was the vehicle towed?(Required)

Yes

No

If yes, “Please provide contact details for the towing company and current location of vehicle, if known.

Is the vehicle able to be driven?(Required)

Yes

No

Vehicle Details

Year(Required)

Make(Required)

Model(Required)

Registration (please use UNREG if unregistered item)(Required)

Damage to your vehicle

eg. damage to the front passenger side door

Is the vehicle under finance?

Yes

No

Preferred repairers name

Repairer phone number

Driver Details

Driver Name

Driver Date of Birth

Address

Street Address Address Line 2 City State Post Code

Contact Number

Years held in current class

License Number

License Expiry Date

License Class

Duty of Disclosure Questions

In the last 5 years has the Policy holder or driver in this incident:

Had a license cancelled or suspended?

Yes

No

Been convicted of a criminal offence?

Yes

No

In the 12 hours prior to driving were any drugs or alcohol consumed?

Yes

No

Did Police attend?

Yes

No

Police name

Was there another vehicle involved in the incident?(Required)

Yes

No

Please provide details

Third Party Details

Name

Date of Birth

License Number (3rd party)

Name of Owner if different to Driver

Address

Street Address Address Line 2 City State Post Code

Vehicle make & model (3rd party)

Registration (3rd party)

Damage to Third Party Vehicle

Insurer

Policy number

Supporting Documents (3rd party)

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 256 MB.

drivers license (front and back, letter of demand - alternatively send these to claims@mackinsure.com.au)

Declaration

Are you the policy holder or are you lodging this on behalf of someone else?(Required)

I'm the policy holder

Behalf of someone else

I/We declare that to the best of my/our knowledge and belief the information in this form is true and correct and I/we have not withheld any relevant information. I/We understand providing false information could result in this claim and potentially this insurance policy being declined/cancelled.

I/We consent to the insurance company using my personal information I/we have provided on this form for the purpose of processing my claim. I/We understand that if I/we choose not to provide required details, this is my/our choice, however, the insurance company may not be able to process my claim.

I/We consent to the insurance company disclosing my personal information to other insurers, an insurance reference service or as required by law. I/We consent to the insurance company also disclosing my personal information to and/or collecting additional information about me, from investigators or legal advisors.

Name(Required)

Date(Required)

Signature(Required)

Additional Claim Notes

Declaration on behalf of

If your claim is being filled out by someone other than the policy holder.

Name(Required)

Date(Required)

Signature (On behalf declaration)(Required)

Additional Claim Notes

Motor Vehicle Claim Form

Policy Details

Incident Details

Vehicle Details

Driver Details

Duty of Disclosure Questions

Third Party Details

Declaration

Declaration on behalf of