Vehicle Accident Report Claim

Vehicle Accident Report Claim

Express Contracting Services TA Golden Brown Cleaning Services: 8/217 Mickleham Rd Tullamrine, Vic 3043
ABN:
Express Contracting Services
Date and Time of Report

DayMonthYearHourMinutesAM/PM Option
Accident Report*
Accident Reported to Police*
Preferred Contact*
Vehicle
Make: Volkswagen Info 1*
Make: Volkswagen Info 2*
Make: Mercedes Info 1*
Make: Mercedes Info 2*
Make: Nissan Info 1*
Make: Nissan Info 2*
Insurance Cost

Excess applicable to Claim Basic Excess $500All drivers up to the age of 21 - Addition to Basic Excess Plus $850Drivers aged between 21 and 25 - Addition to Basic Excess Plus $500Aged greater than 25 but held Aus. Driver Licence for Less than 2 years - BE + $500
Insurance Cover

Third Party Property Damage $30,000,00Windscreen (Don't need to pay Basic Excess Fee)Vehicle Full Accident CoverEquipment and Tools up to $20,000
Insurance Endorsements

Cooling off Period AppliesElectronic Data Exclusion AppliesAsbestos Exclusion AppliesTerrorism Exclusion Applies
Accident Information
ITC%:
Insured
Accident Type

Accident with other carAccident with fix objectTheftVandalise
Accident Details*
Explain how accident happened?
Record Location and Details of Accident
List Item Damaged
List Item Lost
List Item Vandalise
Driver Informaiton
Driver Name

First NameLast Name
Phone Number

Area CodePhone Number
E-mail
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Licence Number:
Expiry Date

DayMonthYear
Years Licenced:
Did the driver drink any alcohol or take any drugs / medication in 12 hours prior to accident?
(If Yes, provide what drugs / alcohol was consumed, the quantity and time consumed)
Send Email to

1 Mail Box2 Mail BoxInstrat Insurance
E-mail Send 1
E-mail Send 2
Instrat Group
Emma James

Tel: 03 9244 7777
Unit4/10 Duerdin St
Clayton Nth, Vic 3168

insur@instrat.com.au

emmaj@instrat.com.au
E-mail Send 3
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