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Lumley Accident Assist AH: 1800 652 256 - page 3 / 4

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Driver's address

Postcode

Driver's phone number

Date of birth

Driver's licence number

Registered owner

Owner's address

Owner's phone number

Area of damage to the other vehicle

5. Third Party Details

Driver's name

Year

Insurance company

Make

(dd/mm/yyyy)

Postcode

Model

Colour

Estimated cost of damage $

Registration number

Did the Police attend the collision / theft scene? If No,was the incident reported to Police? If Yes,which Police Station?

Yes

No

Yes

No

Phone number

7. Police Involvement

Address

Age

Postcode

6. Witness Details

Name

Who do the Police consider was at fault?

Driver

Third party

8. Details of the Loss/Damage

Date (dd/mm/yyyy)

Time

am

pm

Where did the loss / damage occur?

Who do you consider responsible for the loss / damage,and why?

Describe the weather at the time of the loss / damage.

What speed were the vehicles travelling at the time of the loss / damage occurring?

Your vehicle

Other vehicle

3.

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