Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. Motor Vehicle Claim Form – Page 1 of 4

Important information• Do not admit liability – Ask for any claim to be put in writing and refer all correspondence to ZURICH AUSTRALIAN INSURANCE LIMITED.

• Make sure you give us all the details about your claim. Attach a separate sheet if you have insufficient space on this form.

• Send all quotations you have received to repair your vehicle and/or any quotations or correspondence you may have received from any other party in relation to this accident.

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Please complete in FULL all sections of this Claim Form and return it to Zurich as soon as possible after the accident. Unless specifically arranged beforehand. No repairs or alterations to the damaged vehicle should be made until approved by Zurich.

Policy number: Client reference number:

Client ABN Division & Cost Centre:

Have you claimed an input tax credit on the GST applicable to this Policy? Yes No If 'Yes', state percentage claimed %

Insured

Name of insured

Address State Postcode

Phone number Occupation

Are you the sole owner of the insured vehicle? Yes No

Advise the date vehicle was purchased by you/your company? / /

If 'No', name of other interested parties

Is the vehicle leased? Yes No Type of lease: Novated Other

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Motor VehicleClaim form

Privacy• We need personal information about you to assess your claim. We will, where relevant, disclose your personal information (other than

sensitive information such as health information) to your adviser (and any licensee or broker he or she represents), to our service providers (including loss adjusters and investigators), other insurers, insurance reference bureaus and our business partners for this purpose;

• Where relevant, to assess your claim we will also disclose personal information, including sensitive information about you such as health information, to medical practitioners, other health professionals, other insurers and reinsurers, legal representatives, and other consultants. By signing this Claim Form, you consent to those organisations and other professionals collecting, and us disclosing sensitive information about you for this purpose;

• In some cases, assessment and settlement of the claim is undertaken in conjunction with our insured. For example, we may act as an agent for our insured or the cost of claims may be shared between us and our Insured. In these cases, your personal and/or sensitive information will be shared between us and our insured (or their representatives) for the purpose of managing the claim;

• A list of the type of service providers, business partners and consultants we commonly use is available on request, or on our website - go to www.zurich.com.au and click on the Privacy link on our home page;

• If you do not provide the requested information or consent to its collection and disclosure as described above, the assessment of your claim may be delayed or we may not accept the claim;

• We may also disclose personal information about you where we are required or permitted to do so by law;

• In most cases, on request, we will give you access to the personal information we hold about you;

• If you would like to find out more, you can contact us by telephone on 132 687, e-mail us at Privacy.Officer@zurich.com.au or write to 'The Privacy Officer' at Zurich Financial Services Australia Limited, PO Box 677, North Sydney, 2059. Please provide details of your policy number/s and/or claim number where known.

General Insurance Code or PracticeZurich Australian Insurance Ltd is a signatory to the General Insurance Code of Practice. For more information about the General Insurance Code of Practice please go to www.zurich.com.au and select About Zurich.

Brokers please note: You can monitor the progress of a claim via Zurich Claims Online 24 Hours a Day, 7 days a week.

Motor Vehicle Claim Form – Page 2 of 4

Insured vehicleMake and Model Year Colour

Rego number Engine number Chassis or VIN number

CLASS OF VEHICLE

Sedan or Station Wagon Four Wheel Drive Heavy Plant Rigid Vehicle over 2T and up to 5T

Van or Utility up to 2T Bus or Coach Articulated Prime Mover Rigid Vehicle over 5T and up to 10T

Semi Trailer Light Plant Rigid Vehicle over 10T Other

Trailer details (if applicable):

Make Type Year Rego. Number

State any non-standard accessories/modifications to vehicle?

What was the intended operating radius of the journey?

State time and place journey commenced and intended destination

State type and weight of goods being carried?

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DriverFor Parked or Unattended vehicles, Driver or Vehicle Custodian at the time of loss.

Surname Given name(s)

Address State Postcode

Phone number Date of birth / / Age Sex: Male Female

Current Driver’s Licence number and endorsements

Expiry date / / Years Licenced to drive this type of vehicle

Name of registered owner of the vehicle

Are you an employee? Yes No If 'No', state relationship

Have you had any traffic convictions and/or traffic offences or been involved in any motor vehicle accidents in the past five (5) years?

Yes No If 'Yes', please give details

How many hours have you spent driving in the 48 hours immediately preceeding the accident?

Did you consume any alcohol or take any drugs during the 12 hours prior to the accident? Yes No

If 'Yes', state what, how much and when

Did you undergo a breath test or blood test for alcohol or drugs? Yes No

If 'Yes', what was the result

Did you refuse to undergo any of the above tests? Yes No

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Damage to insured vehicle

Was your vehicle damaged? Yes No If tyres damaged, approximate mileage of tyres

Was your vehicle towed away? Yes No If 'Yes', name of company

Have you obtained 2 repair quotes? Yes No Lowest quote $ (Attach all quotes)

Who is your preferred repairer?

Is the vehicle there? Yes No If 'No', where is the vehicle located? (Full address)

Full address State Postcode

Phone number

Show the damaged areas to your vehicle on the following diagram

NO REPAIRS OR ALTERATIONS TO THE DAMAGED VEHICLE SHOULD BE MADE UNTIL APPROVED BY ZURICH AUSTRALIAN INSURANCE LIMITED.

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Motor Vehicle Claim Form – Page 3 of 4

Accident details

Date / / Time AM PM Vehicle Use: Business Private

Day of the Week: Monday Tuesday Wednesday Thursday Friday Saturday Sunday

LOCATION: Street Suburb Postcode

How did the incident or theft happen?

Please draw a plan of the accident. Show the nearest cross street; street names; centre of the roadway; direction and location of vehicles. It is important to detail all road signs and marking and width of road.

Indicate your own vehicle as Indicate any other vehicles asA B

Who do you consider was at fault? Myself Other Driver Other

Why?

Estimated speed of your vehicle 30 metres prior to accident? KPH

Estimated speed of your vehicle at impact? KPH

Estimated speed of the other vehicle just before the accident? KPH

What lights if any were being used by you?

What lights if any were being used by the other party?

What signals were given by you?

What signals were given by the other party?

How far from the point of collision were you when your first saw the other party?

How far from the point of collision was the other party when first seen by you?

State of road/road surface: Smooth Rough Wet Dry Uphill Downhill Flat

How was visibility? Good Moderate Poor

Were there any witnesses to the accident? Yes No If 'Yes', please provide names and addresses

Police questions

Did police attend the accident? Yes No Police report number

If 'Yes', Police Station Name or number of Police officer

If 'No', state time and date reported to Police

Did the police indicate who was responsible Yes No If 'Yes', name of driver

Did police charge wither driver or suggest action may be taken later? Yes No Charge

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Motor Vehicle Claim Form – Page 4 of 4

Damage to other vehicles or property

Vehicle / Property No. 1 Vehicle / Property No. 2

Name of other driver

Address

Age

Phone number

Licence number

Vehicle Make & Model

Registration number

Name of registered owner

Address

Phone number

The other insurance company

Policy number

Description of damage

Personal injuriesWas anyone injured in the accident? Yes No

Name Type of injury Injury party (Passenger/Driver)

Vehicle (registration number)

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Print FormSave File

DeclarationThe information and answers given above. are true in every detail and no information has been withheld.

Driver's signature Name (please print) Date

✗ / /

Authority to move the vehicle to ensure safekeeping. Whilst the claim is under consideration I/We consent to the vehicle being moved to Zurich’s preferred salvage provider for safe keeping. If indemnity is not provided, these costs will be borne by insured company.

Zurich Australian Insurance Limited does not admit liability by the issue of this Claim Form. This form is issued simply to enable the insured to lodge a written statement of claim.

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Insured's signature Name (please print) Date

✗ / /

Signature Title Date

✗ / /

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