Car Wash Claim Form

Name

This field is for validation purposes and should be left unchanged.

Insured Details

Name of the Insured*

Trading Name

Policy Number*

ABN*

Are you Registered for GST?

Yes

Input Tax Credit Entitlement %

Name of the Person Providing Information*

Phone Number of the Person Providing Information*

Email*

Occupation Details*

Incident Details

Date of Incidence*

Time of Incidence*

Location of Incidence*

Incidence Details*

Motor Vehicles Involved in the Incidents

Were there any motor vehicles involved in the incident?

Yes

Motor Vehicles Involved in Incident Details

Make

Model

Year

Engine Number

VIN Number

Rego Number*

Was the vehicle moving or stationary?

Moving

Stationary

Driver Full Name*

Date of Birth*

Type of License*

Year License Obtained*

Email Address*

Contact Phone Number*

Responsible Party

In your opinion, who is responsible for the incidence?

Insured or their Employee

Contractor or Sub-contractor

Third party

If you consider the Contractor / Sub-contractor or Third Party to be responsible, please provide details below:

Full Name

Address

Phone Number

Witness Details

Were there any witnesses to the incident?

Yes

Witness Details

Witness Name

Witness Address

Witness Phone Number

Witness Email Address

Add more

Party Claiming Against You

Name*

Address

Phone*

Email*

If You Need to Provide More Details

Documents Attached

Photos of the incident

Yes

Quotes / Invoices

Yes

Photos of the incident

Drop files here or

Max. file size: 100 MB.

Quotes / Invoices

Drop files here or

Max. file size: 100 MB.

Declaration

I/We declare that to the best of my knowledge these particulars are truthful, accurate and complete

Signature

Full Name

On Behalf Of

Date

Insured Details

Incident Details

Motor Vehicles Involved in the Incidents

Responsible Party

Witness Details

Party Claiming Against You

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

Car Wash Claim Form

Insured Details

Incident Details

Motor Vehicles Involved in the Incidents

Responsible Party

Witness Details

Party Claiming Against You

Documents Attached

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Pump

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

Your duty of disclosure

QBE Privacy

UAA Privacy

Declaration

General Information