Hollard Insurance - Incident Claim Form

1. Policy holder information

Policy holder name

What is your policy number?*

Are you a Business or an Individual?*

BusinessIndividual

Business Name (optional)

First name*

Surname*

Policy holder address

Street Number

Street Name

Street Type

Suburb*

Postcode*

State / Territory

Your Contact Details

Are you the policy holder?*

Yes No

First name*

Surname*

Mobile

Home Phone

Work Phone

Email*

Your preferred method of contact*

MobilePhoneEmail

Best time of day to contact you

AMPM

Nominate a representative to speak on your behalf

2. Claims details

Incident Information

Tell us in detail what happened*

What was the weather condition?

What was the road condition?

Is it alleged that anyone involved in the accident consumed alcohol or took any drugs within 12 hours prior to the incident?

Driver Details

First name of the person driving your car

Surname of the person driving your car

Driver licence number

Is the driver's licence valid?

Yes No

How long has the driver held a drivers licence?

Driver licence expiry date

Date of birth

Is the driver nominated on the insurance policy?

Yes No

Incident Location

Street Number

Street Name

Street Type

Suburb*

Postcode*

Location (if address unknown)

State / Territory

Date and time of the incident*

Your Car

Other car and driver

Did you obtain information about the other driver/s?*

YesNo

Third Parties

Third Party 1

First name

Surname

Street Number

Street Name

Street Type

Suburb

Postcode

State / Territory

Phone

Licence Number

Car registration number

Other driver's insurance company

Other driver's policy or claim number

Third Party 2

First name

Surname

Street Number

Street Name

Street Type

Suburb

Postcode

State / Territory

Phone

Licence Number

Car registration number

Other driver's insurance company

Other driver's policy or claim number

Third Party 3

First name

Surname

Street Number

Street Name

Street Type

Suburb

Postcode

State / Territory

Phone

Licence Number

Car registration number

Other driver's insurance company

Other driver's policy or claim number

Reported to Police

Was the incident reported to the Police?

YesNo

Did the Police attend?

YesNo

Did the Police indicate the responsible party?

YesNo

Responsible Party

Driver of my vehicleOther party

Name of Officer

Police station the officer was from

Event/Report number if provided

Injury

Was there anybody injured?

YesNo

Incident Claim Notification

Policy holder name

Policy holder address

Your Contact Details

Incident Information

Driver Details

Incident Location

Your Car

Other car and driver

Third Parties

Reported to Police

Injury