Motor Claim Form

  • 1. Insured Or Company Details

  • 2. Vehicle Details

  • 3. Driver Details














  • Date Format: DD slash MM slash YYYY


  • Date Format: MM slash DD slash YYYY

  • No repairs of alterations to the damaged vehicle should be made until the Insurers have approved repairs.

    Failure to do so could result in your Insurer being prejudiced and any costs which are not assessed as fair and reasonable will not be covered by Insurers meaning an out of pocket cost to yourself.

  • 4. Details Of The Accident


  • Date Format: MM slash DD slash YYYY

  • :

  • What speed were the vehicles travelling at the time of the loss/damage occurring? (If applicable)

  • (weather, lighting and condition of road)
  • Drop files here or

  • 5. Third Party Details











  • Date Format: MM slash DD slash YYYY

  • If the Third Party Driver is not the registered owner of the vehicle, please complete the following:










  • Drop files here or

  • 6. Theft Of Vehicle

    (Yes is required for all malicious damage or theft/burglary claims)

  • 7. Witness Details

    (Witnesses cannot be friends, family or someone who you know)










  • 8. Police Involvement

  • Please provide details

  • 9. Declaration

    I declare that to the best of my knowledge and belief the information in this form is true and correct and I have not withheld any relevant information.
    I/we agree that, by submitting this form, the personal information I/we provide to PSC Connect Pty. Ltd. in this form or otherwise may be collected, held,
    used and disclosed in the manner set out in the PSC Privacy Policy found at www.pscconnect.com.au/privacy, including for processing this claim.


  • Date Format: DD slash MM slash YYYY