AIS Insurance PTY LTD. Specialising in Service
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New Claims Report - Motor Vehicle:  
   
Date:
Time:
Ins Company & Policy Type
Insured Name & Client Code
Contact Name:
Mobile:
Other: 
ABN No & ITC %
Date & Time of Loss:
Situation of loss: - Street: 
Suburb

Incident description:

Estimate: $
Police attend - Yes / No:   
Report Number
Station & Officer Name
Vehicle Make & Rego:
Location of vehicle:
Is Vehicle Drivable - Yes/No
Driver’s Name
Date of Birth
Licence number & Expiry
Yrs Licenced:
Alcohol/drugs in last 24 hrs - Yes/No
Breathalyser/Blood test taken: - Yes/No
Third Party details
Name
Address
Phone numbers
Vehicle & rego
Insurer

Claim Form Sent – Yes / No

Repair quotes obtained - Yes / No
 
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