COVID-19 Updates >
team@avisowa.com.au
Email the team
08 6274 0500
Give us a call
Make a Payment
About
Our Staff
Aviso Group
About Aviso Group
Industry Partners
Products & Services
Business Insurance
Personal Insurance
Specialist Insurance
Industries
Mining Insurance
Rural & Farm Insurance
Premium Funding
Claims
News & Resources
News
Calculators
Resources
Key Documents
Contact us
toggle menu
team@avisowa.com.au
Email the team
08 6274 0500
Give us a call
Make a Payment
About
Our Staff
Aviso Group
About Aviso Group
Industry Partners
Products & Services
Business Insurance
Personal Insurance
Specialist Insurance
Industries
Mining Insurance
Rural & Farm Insurance
Premium Funding
Claims
News & Resources
News
Calculators
Resources
Key Documents
Contact us
toggle menu
Motor Insurance Claim Form
Your Name:
*
First
Last
Your Phone:
*
Your Email:
*
Is this Vehicle insured under a Business Name?
*
Yes
No
Please Enter Your Business Name:
*
Who shall we contact with claim updates?
*
Me
Someone else
Please enter the email for our point of contact for this claim
*
Were you driving at the time?
Select
Yes
No
It was parked
Name of the driver at the time
*
First
Last
Driver Date of Birth
*
MM slash DD slash YYYY
How many years has the Driver held a full driving licence for? (Excluding L Plates)
*
Has the Driver had any traffic offences or licence suspensions in the last 5 years?
-Select-
Yes
No
If Yes please provide details
What time did it happen?
Hours
:
Minutes
AM
PM
AM/PM
When did the accident happen?
*
MM slash DD slash YYYY
What Happened?
A brief description of what occurred (20 words or less). If you want to provide a longer description of what occurred please enter it below.
Longer Description of What Occurred (Optional)
If you want to provide a more detailed description of what occurred please enter it in this box.
Your Vehicle Registration No.
*
Where did the accident happen?
*
Street Address
City
Your Vehicle Year, Make and Model
Where is your vehicle?
Select
At repairers
Still in use
Repairer's Address
*
Repair Name
Street
City
State / Province / Region
Phone
*
Do you have a Preferred Repairer you want to use?
*
Yes
No
Preferred Repairer's Address
*
Repair Name
Street
City
State / Province / Region
Phone
*
Did the Police attend?
Select
Yes
No
Were you breathalysed or drug tested?
Select
Fist Choice
Second Choice
Third Choice
Was there a Third Party involved in the accident?
Select
Yes
No
Who do you think was at fault?
Select
You
The Third Party
Not Sure
Third Party details
First
Last
Address of Third Party
Street Address
City
State / Province / Region
Third Party's Phone Number
Third Party Registration No.
Was there a witness?
Select
Yes
No
Witness Details
Name
Address
City
State / Province / Region
ZIP / Postal Code
Witness' Phone Number
Please upload photos of drivers licence, photos of damage and Third Party licence ( if applicable)
Drop files here or
Select files
Accepted file types: pdf, docx, Max. file size: 128 MB, Max. files: 5..
Your Signature:
*
Accepted file types: jpg, gif, png, Max. file size: 128 MB.
Date and Time Completed
*
MM slash DD slash YYYY
CAPTCHA
Δ
Have a question?
Our insurance brokers are standing by, ready to help.
Get in touch
team@avisowa.com.au
Contact
toggle menu
About
Our Staff
Aviso Group
About Aviso Group
Industry Partners
Products & Services
Business Insurance
Personal Insurance
Specialist Insurance
Industries
Mining Insurance
Rural & Farm Insurance
Premium Funding
Claims
News & Resources
News
Calculators
Resources
Key Documents
Contact us
08 6274 0500
team@avisowa.com.au
Make a Payment