Motor Vehicle Claim Form

Complete our free and confidential online application

To start the process of making a motor vehicle claim, complete the online form below, or download and complete the PDF version of the form and follow the instructions to return it to our team.

Act now to take the first step on the path to recovering your losses.

Download PDF form

Fill out the form below

"*" indicates required fields

Step 1 of 7

Full name of registered owner of the vehicle

Title

Name*

First Name Last Name

Your contact details

Mobile*

Email address*

Enter Email Confirm Email

We will generally communicate with you via email unless you specifically request otherwise.

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone

Occupation

License Number*

Are you registered for GST?*

Yes

Please enter your ABN

Were you the driver of the vehicle at the time of the accident?*

Yes

Who was the driver of vehicle at the time of the accident?

Title*

Name*

First Name Family Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

DOB*

What is your relationship to the driver?*

The Accident

Date of accident*

Time*

24-hour time, approximate time is acceptable if exact time is unknown.

Provide a summary of how the accident occurred

Who, in your opinion, was responsible for the accident?*

Where did the accident occur?*

Please upload a diagram of your accident

Max. file size: 50 MB.

Damaged items

What items were damaged?*

Helmets

Riding gear

Baby seats

Prams

Other

Other damaged items

Other driver's details

Title*

Name*

First Name Last Name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone*

License Number*

Approximate age*

Make*

Model*

Rego Number*

Detail damage to other vehicle

Was the vehicle towed*

Yes

Is the vehicle insured?*

Yes

If yes, which company?*

Claim number / Policy number*

I authorise AIC Lawyers with address at Ground Floor, 485 La Trobe St, Melbourne, VIC 3000, to contact me and discuss my motor vehicle collision.*

I agree to:

- refer any contact from the other party/insurers to AIC Lawyers;
- provide to my lawyers all reasonable assistance and cooperation in relation to these instructions; and
- notify AIC Lawyers of any change of address by me and confirm that should I fail to do so, they are entitled to consider themselves no longer bound by my instructions.

I acknowledge that AIC Lawyers are relying upon the information supplied by me as to the circumstances and particulars surrounding the collision.

Name*

First Last

Date*

Phone

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

Motor Vehicle Claim Form

Complete our free and confidential online application

Full name of registered owner of the vehicle

Your contact details

Who was the driver of vehicle at the time of the accident?

Your vehicle

The Accident

Damaged items

Other driver's details

Injuries

Police

Witnesses / Passengers