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Not At Fault
Make A Claim
About
Contact Us
Home
Not At Fault
Make A Claim
About
Contact Us
Claim Application
Your Details
Owner of vehicle (on registration)
Email
Phone
Owner Address
Vehicle Details
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Registration
Licence Details
Licence Number
Licence State
ACT
NSW
NT
SA
TAS
QLD
VIC
WA
Licence Expiry
Licence Photo
Registration Document
Note:
Please send us a photo of your registration document. You can also get this by logging into your Vic Roads account.
Click here
for instructions on how to do this.
At-Fault Driver Details
Full Name
Address
Phone
Date Of Birth
Email
Licence Number
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Registration
Accident Details
Date of Accident
Accident Location
Accident Description
Insurance Details of Other Driver
Insurance Company
Claim Number
Is Your Car Driveable?
Yes
No
I confirm that the details in this form are accurate and correct
Yes
I have read, understand and accept the Terms and Conditions on this page.
Yes
I authorise Car Rentals Near Me to act on my behalf in recovering the replacement vehicle costs, communicating with the insurer in regards to the claim and commencing legal proceedings if the matter is in the situation where it must be defended in a court of law
Yes
Accepted & Digitally Signed By:
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