Motor Vehicle Windscreen Claim Form

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*

Date of Incidence*

Time of Incidence*

Location of Incidence*

Insured Vehicle Details

Make

Model

Year

Engine No.

Vin No.

Rego No.*

Insured Vehicle Driver’s Details

Full Name*

Date of Birth*

Contact Phone Number*

Email*

Address*

Licence No.*

Expiry*

Licence Class*

State Licence Issued*

Country Licence Issued*

Incident Details

Weather Conditions*

Road Conditions*

Estimated speed of your vehicle*

Estimated speed of other vehicle, if involved*

Driver was Driving From*

Driver was Driving To*

The purpose of journey was*

Was another vehicle involved in the incident?*

Yes

What is your reason for thinking so?*

Describe below how the incident occurred*

Documents to be Attached

Please attach the following documents

Copy of Insured Driver License*

Yes

N/A

Photos of Damaged Insured Vehicle*

Yes

N/A

Copy of Insured Driver License

Drop files here or

Max. file size: 100 MB.

Photos of Damaged Insured Vehicle

Drop files here or

Max. file size: 100 MB.

Declaration

Do you understand that, to the best of your knowledge and belief, the information in this form is true and correct and that the claim may be refused or reduced if information is not true or withheld?*

Yes

Do you understand that you may have to provide further relevant documentation to enable complete consideration of this claim?*

Yes

Signature*

Name*

Date*

Do you have an existing business?*

Yes

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

Any motor claim history in last 5 years*

Yes

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

Finish Date Requested

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

Any driver with less than 2 years of driving experience?*

Yes

Any driver had his/her licensed cancelled or suspended within the last 5 years?*

Yes

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

Cover amount

Marine Cargo (M.C.) Cover Required.*

Yes

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

Number of weeks required

Number of Vehicle required

Limit required for each vehicle. Per week

Truck Details

Registration Number*

State of Registration*

Year*

Truck: Make & Model*

Truck: Body Type*

Truck: Payload Or GVM*

Refrigerated?*

Yes

VIN*

Engine No.*

Transmission Type*

Auto

Manual

Sum Insured Required*

What you carry?*

No. of claims on this vehicle*

DG Sum Insured Required*

Registered Owner*

Trailer In Control (TIC) Reqd:*

Yes

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

Interested Party Name*

Add more

Duty Of Disclosure

Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership, or liquidation in the last 5 years?*

Yes

N/A

Has any owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?*

Yes

N/A

Has any owner/director or officer of the business, or the business itself been convicted of a criminal offence in the last 10 years?*

Yes

N/A

In the past 5 years have your or any of your drivers had any license suspended, cancelled, or amended to provisional; Or any alcohol or drug conviction; Or any dangerous driving offence; Or any offence involving with a speed limiter?*

Yes

N/A

In the past 5 years, how many speeding offences > 15kph in a heavy vehicle or Red-Light Offences you or any of your drivers have received?*

Yes

N/A

Is any Motor Vehicle lent out, leased out, or control assigned to any other party (ie. Dry Hired)?*

Yes

N/A

Do you or any of your driver have a physical or mental ailment/condition that detracts from your driving ability?*

Yes

N/A

Do you perform any high-risk activities?*

Yes

N/A

Had any insurance declined, cancelled, refused or special conditions/terms imposed, or claim refused?*

Yes

N/A

Had any convictions which are less than 10 years old (adult), 5-year-old (juvenile), or if outside of these years any convictions that have had a prison sentence greater than 30 months?*

Yes

N/A

Previous Insurance Company?*

Yes

N/A

Signature*

Name*

On Behalf of*

Date*

Do you have an existing business?*

Yes

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

Any motor claim history in last 5 years*

Yes

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

Finish Date Requested

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

Any driver with less than 2 years of driving experience?*

Yes

Any driver had his/her licensed cancelled or suspended within the last 5 years?*

Yes

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

Cover amount

Marine Cargo (M.C.) Cover Required.*

Yes

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

Number of weeks required

Number of Vehicle required

Limit required for each vehicle. Per week

Truck Details

Registration Number*

State of Registration*

Year*

Truck: Make & Model*

Truck: Body Type*

Truck: Payload Or GVM*

Refrigerated?*

Yes

VIN*

Engine No.*

Transmission Type*

Auto

Manual

Sum Insured Required*

What you carry?*

No. of claims on this vehicle*

DG Sum Insured Required*

Registered Owner*

Trailer In Control (TIC) Reqd:*

Yes

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

Interested Party Name*

Add more

Duty Of Disclosure

Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership, or liquidation in the last 5 years?*

Yes

N/A

Has any owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?*

Yes

N/A

Has any owner/director or officer of the business, or the business itself been convicted of a criminal offence in the last 10 years?*

Yes

N/A

Yes

N/A

In the past 5 years, how many speeding offences > 15kph in a heavy vehicle or Red-Light Offences you or any of your drivers have received?*

Yes

N/A

Is any Motor Vehicle lent out, leased out, or control assigned to any other party (ie. Dry Hired)?*

Yes

N/A

Do you or any of your driver have a physical or mental ailment/condition that detracts from your driving ability?*

Yes

N/A

Do you perform any high-risk activities?*

Yes

N/A

Had any insurance declined, cancelled, refused or special conditions/terms imposed, or claim refused?*

Yes

N/A

Had any convictions which are less than 10 years old (adult), 5-year-old (juvenile), or if outside of these years any convictions that have had a prison sentence greater than 30 months?*

Yes

N/A

Previous Insurance Company?*

Yes

N/A

Signature*

Name*

On Behalf of*

Date*

Motor Vehicle Windscreen Claim Form

Insured Details

Insured Vehicle Details

Insured Vehicle Driver’s Details

Incident Details

Documents to be Attached

Please attach the following documents

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