Motor Claim Notification URLThis field is for validation purposes and should be left unchanged.General DetailsWhich branch do you deal with?* Maroochydore Townsville Proserpine Mackay Ingham Insured Name*Contact Name*Contact Number*ABNITC %Policy DetailsPolicy Number*Unit NoInsurerExcessLoss DetailsDate of Loss*Address of Loss*TimeAccident Description*Accidental DamageEvent (Cyclone / Earthquake, etc.)FireFloodStorm / WaterTheftVandalism / Malicious DamageOtherInsured Vehicle*Registration Number*Vehicle Location*Where is the damage to your vehicle?*Please attach supporting photos/documentation if available Drop files here or Select files Max. file size: 128 MB. Preferred Repairer*Driver DetailsDriver Name*Driver DOB*Licence Number*Licence Class*Licence Expiry Date*State*QLDNSWVICACTTASSAWANTHad the driver had and Alcohol/Drugs in Prev. 12hrs* Yes No Was a Breathalyser Test Taken?* Yes No If yes, what was the result?*Any insurance policies DECLINED in last 5yrs?* Yes No Any convictions or criminal offences in the last 5yrs?* Yes No Licence suspended/refused in the last 5yrs?* Yes No Police DetailsReport NoStationOfficer NameThird Party DetailsContact NamePhone NoAddressVehicle DetailsReg NoInsurerBank DetailsMethod Cheque EFT Bank NameBSBAccount NumberAccount Name Δ