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Graham Lyle Insurance
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Home
About
Insurance
Business Insurance
Business Packs
Commercial Motor Insurance
Professional Indemnity Insurance
Public & Product Liability Insurance
Cyber Insurance
Commercial Strata Insurance
Commercial Landlord Insurance
Farm Insurance
Home Insurance
Home and Contents Insurance
Residential and Landlords Insurance
Residential Strata Insurance
Car & Vehicle Insurance
Commercial Motor Insurance
Private Motor Insurance
Claims
Property Claim
Vehicle Claim
Online Forms
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Vehicle Claim Insurance Application
Your details
Policy Number
(Required)
Have you paid your insurance premium for this claim?
Yes
No
Contact phone number
(Required)
Email Address
(Required)
GST Details
Registered for GST?
Yes
No
Do you claim GST on your premiums paid?
Yes
No
If yes what % do your claim?
Do you claim GST on your claims?
Yes
No
If yes what % do your claim?
ABN Number:
Your Vehicle Details
Description of your Vehicle
Registration Number
Any Unrepaired damages to your vehicle prior to the accident?
Yes
No
Is the vehicle still safe to drive?
Yes
No
Incident Details
Date
Time of Incident
Hours
:
Minutes
AM
PM
AM/PM
Where (Address of incident)
Street Address and City
State / Province / Region
ZIP / Postal Code
Details of Event
Enter your Preferred Smash Repairer name and address OR suburb most convieneiant to you and we will find one for you
Invoice Amounts – if applicable
Where are the damages to your vehicle?
Insured Driver details
Drivers Name
D.O.B
License Number
Expiry Date
Any licence suspensions within the last 5 years?
Yes
No
Any licence suspensions within the last 5 years?
Yes
No
Held licence for more than 2 consecutive years?
Yes
No
License still current at time of incident?
Yes
No
Any drugs or alcohol consumed 12 hours prior?
Yes
No
Any Emergency Services Attend?
Yes
No
Police Report Number:
In the past 5 years, has the policyholder or the driver in this incident had an insurance policy declined, cancelled or conditions imposed on an insurance policy?
Yes
No
Third Party Details
Where are the damages to other party’s vehicle (if applicable)
Third Party Name
Address
Phone Number
Vehicle Details
Any other details regarding the third party?
EFT DETAILS
Name of Bank:
Account Name:
BSB Number:
Account Number:
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(Required)
I confirm that all above information's are correct.
(Required)
