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Lumley Accident Assist AH: 1800 652 256 - page 2 / 4

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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

Insured/Company

Custom Service Leasing Pty Ltd

Division

org unit no.

Address

Postcode

Policy number

SYMO 0077 2569 Academic/Support Staff - Operating & Novated Lease

Phone number

Email

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

100

%

and (ii) vehicle which is the subject of this claim

%

2. Client Vehicle Details

Year

Make

Model

Colour

Registration number

Finance company (if applicable)

Use of the vehicle at the time of the loss/damage ()

Private

Business

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 ()

Collision

(go to Section 4)

Theft

(go to Section 6)

Hail/Flood/Fire/Windscreen

(go to Section 8)

4. Driver Details

Driver ()

Employee

Family Member

Other

Name

Address

Postcode

Phone number

Mobile number

Drivers licence number

Class

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?

Yes

No

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?

Yes

No

Yes

No

If Yes,please state the result

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