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

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Section 8 cont... Describe how the loss / damage occurred.

Was there any damage to your vehicle prior to this loss/damage occurring? If Yes,please provide details.

Yes

No

Please indicate on the diagram below,the area of damage to your vehicle by marking the cross box closest to the damage

Front

Rear

Was your vehicle towed from the accident scene? If yes,by whom and to where was it towed?

Yes

No

Is your vehicle currently at a repair shop?

Yes

No

If yes,at which repair shop?

If no,please provide contact details so we may arrange to assess damage to your vehicle

8. Declaration

This information is,to the very best of my knowledge, true inevery respect.

Name of the Driver who is responsible for the car at UTS

Name of your supervisor at UTS

Date (dd/mm/yyyy)

Please print the form for your copy

Save: To save the completed form(with the data) please save the form on your computer with a different name. The data will be lost if you close the form without saving. Email: start new email message, attach the form saved on your computer and email it to: scobb@lumley.com.au or shau@lumley.com.au Address: Lumley House Level 9, 309 Kent Street, Sydney 2000. Fax : 9248 1135 Ph: 9248 1263

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