Pursuant to the PRIVACY ACT 1993 the following is brought to your attention:(a) This claim form collects personal information about you(b) The information is collected to evaluate your claim(c) The collection of this information is required pursuant to the terms of your insurance policy;(d) The failure to provide this information may result in your claim being declined;(e) You have the rights of access to, and correction of, this information subject to the provisions of the Privacy Act 1993
DECLARATION: Note: Failure to provide full and truthful information could result in the claim being declinedI/We declare that the information given in this form is correct.I/We authorise and request the Australian Police to release Travellers Autobarn copies of any documents held by the Australian Police relating to the incident giving rise to this claim. If necessary, authority should be treated as a formal request pursuant to the Official Information Act, 1982.I/We authorise the disclosure of personal information held by any other party regarding this claim. I/We agree to Travellers Autobarnreleasing to other parties personal information regarding this claim.I/We authorise the insurer or its authorised agent to give or obtain from the other insurers or other parties any information relating toany insurance held or claim made.I/We authorise you to place details of this claim on the database of Travellers Autobarn where it will be retained and be available toother insurance companies to inspect.I/We solemnly declare that the information given & contained in this document is true & correct by virtue of the Oaths & DeclarationsAct, 1957.I/We acknowledge that if any information given is incorrect or has been concealed it may result in the claim being declined.
I HAVE READ THE ABOVE & DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE ANSWERS PROVIDED IN THIS FORM ARE TRUTHFUL