Car insurance claim

You are about to submit this claim form with the product issuer, QBE Insurance. Once you submit this form, an ANZ Claims specialist will contact you within 2 business days.

* Required fields

Policy details

Policy number

Are you the policy holder?

Yes No

Policy holder's details

Given name

Family name

Preferred contact number

Preferred phone area codePreferred phone number Preferred mobile number

Email address

Preferred contact method

Email Phone

Street address

Suburb/town

State

Postcode

Incident details

Date incident occurred (DD/MM/YYYY)

Approximate time

Where did the incident occur?

Street address

Suburb/town

State

Postcode

Incident description

Detailed description of incident/loss

Is the car drivable?

Yes No

Does the car require a tow?

Yes No

Where is the car now? (address)

Have you obtained any quotes to repair the damage?

Yes No

Car details

Registration number

Make

Model

Year of manufacture

Police report details

Have you reported the incident to the police?

Yes No

Police report number

Third party

Was there a third party involved?

Yes No

Name of third party driver

Name of the owner

Insurer

Address

Phone

thirdParty phone area code thirdParty phone number thirdParty mobile number

Registration number

Licence number

Make

Model

Year of manufacture

Witness details

Were there any witnesses?

Yes No

Name

Address

Contact details

Add another witness?

Yes No

Name

Address

Contact details

Add another witness?

Yes No

Name

Address

Contact details

Further driver information

In the last 5 years have you or any of the drivers of your vehicle ...

Had an accident, car stolen or burnt (even if not reported or not claimed for from an insurer)?

Yes No

Had your insurance refused, declined or cancelled by an insurer or special conditions imposed?

Yes No

Had a driver or motorcycle licence cancelled, suspended or endorsed?

Yes No

Been convicted of or charged with drug use, driving under the influence or exceeding prescribed concentration of alcohol?

Yes No

Had any driving offences or issued any speeding or traffic infringements?

Yes No

Been convicted of or charged with fraud, arson, theft or criminal act?

Yes No

Suffered from any physical or mental disability (excluding eyesight corrected by lenses)?

Yes No

Been declared bankrupt, owned or own a business which has been placed into liquidation or had a receiver or administrator appointed?

Yes No

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