Click on the fields to complete online,then print and complete diagram in Section 8 in black or blue pen and sign. OR Print and complete all sections in black or blue pen.
1. Client Details
Custom Service Leasing Pty Ltd
org unit no.
SYMO 0077 2569 Academic/Support Staff - Operating & Novated Lease
Goods and Services Tax:
(a) Australian Business Number (ABN), if applicable
600 732 450 84
(b) entitlement to an Input Tax Credit in respect of:
(i) Insurance premium
and (ii) vehicle which is the subject of this claim
2. Client Vehicle Details
Finance company (if applicable)
Use of the vehicle at the time of the loss/damage ( )
Vehicle Use Descriptions Private not used for business
Business: used while on UTS business including travelling to and from work
3. Claim Details
Claim Type ( )
(go to Section 4)
(go to Section 6)
(go to Section 8)
4. Driver Details
Driver ( )
Drivers licence number
Expiry Date (dd/mm/yyyy)
Date of birth
(dd/mm/yyyy) Driving experience (years)
Did the driver consume any alcohol or take any drugs within the 12 hours prior to the collision?
If Yes,please state how much and when Was the driver sober at the time of the collision? Did the driver undergo a breath or blood test?