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Motor Vehicle Claim Form

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Comments

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

N0

Input Tax Credit Entitlement %

Name of the person providing information*

Phone Number of the Person Providing Information*

Email*

Date of Incidence*

DD slash MM slash YYYY

Time of Incidence*

Hours

:

Minutes

AM/PM

Location of Incidence*

Insured Vehicle Details

Make

Model

Year

Engine No.

Vin No.

Rego No.*

Was there any Load carried in your Vehicle?

Yes

No

Type of Load being carried at the time of accident?*

Weight of load being carried*

Is Insured the registered owner of the Vehicle?

Yes

No

Name

Address

Was the Vehicle being driven/operated with the insured’s consent?

Yes

No

Please Provide Details

Is the Vehicle financed?

Yes

No

Please provide details of Finance Co.

Was any Trailer Attached?

Yes

No

Trailer Info

Trailer Type

VIN No.

Rego No.*

Year

Make & Model

Insured Vehicle Driver’s Details

Full Name*

Date of Birth*

DD slash MM slash YYYY

Contact Phone Number*

Email*

Address*

Licence No.*

Expiry*

Licence Class*

State Licence Issued*

Country Licence Issued*

How long the driver been licensed to drive this class of vehicle in Australia?*

Has the driver’s licence ever been cancelled or suspended?

Yes

No

Please provide details*

Has the driver been involved in any other motor vehicle accident during the last five (5) years?

Yes

No

Previous Accident Details

Date of Accident

Fault / Not at Fault

Details

Claim Amount

Did the driver of the vehicle undergo any Breathalyser, Blood, Urine or Drug test?

Yes

No

Breathalyser Test

Yes

No

Blood Test

Yes

No

Breathalyser Test Results

Blood Test Results

Urine Test

Yes

No

Drug Test

Yes

No

Urine Test Results

Drug Test Results

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

No

Who do you think was responsible for the accident?

Insured Driver

Third Party Driver

Other

What is your reason for thinking so?*

Describe below how the incident occurred*

Did the incident result in damage to another person(s) vehicle(s) or property?

Yes

No

Please Provide Details*

Damage To Your Vehicle

Did the incident result in damage to your vehicle or property?*

Yes

No

Describe the damage to the Vehicle*

Was the Vehicle towed away from scene?

Yes

No

Details of the Tow Company

Has the repair quote been obtained?

Yes

No

N/A

Amount ($)

Obtained Repair Quote

Max. file size: 100 MB.

Is the vehicle drivable?

Yes

No

Address Where vehicle can be assessed

Do you have a preferred repairer?

Yes

No

N/A

Please provide contact details of the preferred repairer.

If the Vehicle was stolen, has it been recovered in a damage condition?

Yes

No

N/A

Third Party Details

Driver Full Name*

Date of Birth*

DD slash MM slash YYYY

Contact Number

Email

Address

Expiry

Licence Type

Third Party Vehicle Details

Make

Model

Year

Engine No.

Vin No.

Rego No.*

State of Registration

Name of their Insurance company

Was there any Load carried in Third Party Vehicle?

Yes

No

Type of load being carried

Weight of load being carried

Witness Details

Were there any witnesses to the incident?

Yes

No

Witness Details

Witness Name

Witness Address

Witness Phone No

Witness Email Address

Add more

Police Details

Was the incident reported to the police Or police attended the incident scene?

Yes

No

Police Station

Police Report No.

Officer's Name

Officer's Number

Police action taken?

Yes

No

Please Provide Details

Documents to be Attached

Please attached the following documents

Copy of Insured Driver License

Yes

No

N/A

Copy of Third Party Driver License, if involved

Yes

No

N/A

Photos of Damaged Insured Vehicle

Yes

No

N/A

Photos of Damaged Property Or Third Party Vehicle, as applicable

Yes

No

N/A

Copy of Police Report, if any

Yes

No

N/A

Copy of Insured Driver License

Max. file size: 100 MB.

Copy of Third Party Driver License, if involved

Max. file size: 100 MB.

Photos of Damaged Insured Vehicle

Drop files here or

Max. file size: 100 MB.

Photos of Damaged Property Or Third Party Vehicle, as applicable

Drop files here or

Max. file size: 100 MB.

Copy of Police Report, if any

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

No

Date

DD slash MM slash YYYY

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

Yes

No

Date

DD slash MM slash YYYY

Signature

Name

Date

DD slash MM slash YYYY

Please draw how the accident happened. Show the nearest cross street, street names, centre of the roadway, direction, location of vehicles, and any other useful information.

Indicate your own vehicle as

Indicate Third Party Vehicle as

Incident Drawing

Max. file size: 100 MB.

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Industries
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About Us
FAQs
Privacy Policy
Contact Us

Protecting your future with tailored insurance solutions.

Contact Us

03 8401 3318
admin@biima.com.au

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Australia Wide

Disclosure: G N Insurance Pty Ltd T/As BIIMA (CAR No. 1233580 | ABN: 15 604 013 523)
Corporate Authorise representative of Community Broker Network Pty Ltd | AFSL 233750 | ACN 096 916 184)

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First Name(Required)

Last Name

Phone Number(Required)

Email(Required)

Type of Insurance Needed(Required)

Type of insurance needed (if other)

Further Details

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Do you have an existing business?*

Yes

No

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

DD slash MM slash YYYY

Any motor claim history in last 5 years*

Yes

No

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

MM slash DD slash YYYY

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

DD slash MM slash YYYY

Finish Date Requested

DD slash MM slash YYYY

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

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

Yes

No

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

Yes

No

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

No

Cover amount

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

Yes

No

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

No

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

No

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

No

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

No

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

No

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

No

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

No

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

No

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

No

N/A

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

Yes

No

N/A

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

Yes

No

N/A

Do you perform any high-risk activities?*

Yes

No

N/A

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

Yes

No

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

No

N/A

Previous Insurance Company?*

Yes

No

N/A

Signature*

Name*

On Behalf of*

Date*

DD slash MM slash YYYY

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Get acquainted, explore market-leading business insurance solutions and find the right fit.

"*" indicates required fields

Step 1 of 5

20%

Do you have an existing business?*

Yes

No

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

DD slash MM slash YYYY

Any motor claim history in last 5 years*

Yes

No

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

MM slash DD slash YYYY

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

DD slash MM slash YYYY

Finish Date Requested

DD slash MM slash YYYY

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

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

Yes

No

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

Yes

No

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

No

Cover amount

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

Yes

No

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

No

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

No

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

No

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

No

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

No

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

No

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

No

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

No

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

No

N/A

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

Yes

No

N/A

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

Yes

No

N/A

Do you perform any high-risk activities?*

Yes

No

N/A

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

Yes

No

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

No

N/A

Previous Insurance Company?*

Yes

No

N/A

Signature*

Name*

On Behalf of*

Date*

DD slash MM slash YYYY

×

Get acquainted, explore market-leading business insurance solutions and find the right fit.

"*" indicates required fields

Phone

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

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

Date

DD slash MM slash YYYY

Years in Business

Policy No.

Insured Name

Insured Email*

Suburb

Postcode

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Truck details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Pump

Pump Details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

External Service Providers.

Yes

No

In House by Your Own Employees.

Yes

No

How often does maintenance/servicing take place?

Are all your concrete pumping machines certified in accordance with Australia Standard AS2550 and/or AS2550.15?. If no, provide reasons why in space provided

Yes

No

Reasons

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

File

Drop files here or

Max. file size: 100 MB.

Claims and/or circumstances list

Year

Claim Details

Incurred

Your duty of disclosure

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms. You have this duty until we agree to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell us anything that:

Reduces the risk we insure you for; or
Is common knowledge; or
We know or should know as an insurer; or
We waive your duty to tell us about.

If you do not tell us something If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.

If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

QBE Privacy

We will collect personal information when you deal with us, our agents, other companies in the QBE group or suppliers acting on our behalf. We use your personal information so we can do business with you, which includes issuing and administering our products and services and processing claims. Sometimes we might send your personal information overseas. The locations we send it to can vary but include the Philippines, India, Ireland, the UK, the US, China and countries within the European Union.

Our Privacy Policy describes in detail where and from whom we collect personal information, as well as where we store it and the full list of ways we could use it. To get a free copy of it please visit qbe.com.au/privacy or contact QBE Customer Care.

It’s up to you to decide whether to give us your personal information, but without it we might not be able to do business with you, including not paying your claim.

UAA Privacy

UAA is committed to protecting the privacy of personal information in accordance with the Privacy Act 1988 (Cth). UAA’s privacy principles, set out at www.uaa.com.au, explain what personal information is collected from the Insured, why it is collected, how it will be used and to whom it can be disclosed

Declaration

Please remember we will treat a statement or claim or an act or omission by any one of the applicants as a statement or claim or an act or omission by all of the applicants.

I/ We have received a copy of the Policy wording QM2003
I/We declare that all answers and statements made in the application are true, correct and complete in every respect.

Signature

Signature of applicant

Add more

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General Information

Full Insured Name

Trading Name

ABN

Are you a Licensed Real Estate Agent or an Authorised Rep. of a Licensed Real Estate Agent?

Contact Person

Phone

Designation of the person providing information

Main Office Address

Postal address

Address of any branch or office

Office Phone

Email

Web Address

Do you have Professional Indemnity insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Do you have Public Liability insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Do you have Management Liability insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Has the firm, any partner, principal or director ever been refused this type of insurance, had special terms imposed, had a policy cancelled or had an application for renewal declined?

Yes

No

Please Provide full Details

Privacy Policy

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