________
________
________
________
Date: ________
To:
________
________
Re: Vehicle Insurance Claim – Policy No. ________
Dear Sir or Madam,
I refer to my contract of motor vehicle insurance with ________ (the Insurer) and write to lodge a claim under that policy in accordance with its terms and with the Insurer's obligations under the Insurance Contracts Act 1984 (Cth) and the General Insurance Code of Practice.
§1. Details of the Incident
On ________ at approximately ________, at ________, I was involved in an incident, the particulars of which are as follows:
________
The above particulars are true and correct to the best of my knowledge and belief. I confirm that I have complied with my duty to take reasonable care not to make a misrepresentation, as required under sections 20B and 21 of the Insurance Contracts Act 1984 (Cth).
§2. Particulars of the Claim
Policyholder: ________
Policy Number: ________
Date Policy Commenced: ________
Vehicle Make and Model: ________
Vehicle Identification Number (VIN): ________
Registration Number: ________
Driver at the Time of Incident: ________
Driver's Licence Number: ________
Police Report / Event Reference Number: ________
Total amount claimed: $________
§3. Supporting Documentation
In support of this claim, I enclose the following documentation:
(a) a completed claim form;
(b) a copy of the police report or event number;
(c) a quotation for repairs to the vehicle;
(d) a valuation report for the vehicle;
(e) evidence of the expenses incurred; and
(f) the following additional enclosures:
________
§4. Requested Settlement
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________
§5. Time for Response and Complaints
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§6. General
I authorise the Insurer to collect, use and disclose my personal information for the purposes of assessing and processing this claim in accordance with the Privacy Act 1988 (Cth) and the Insurer's privacy policy. I reserve all rights available to me under the policy and at law.
If you require any further information or documentation in order to process this claim, please do not hesitate to contact me using the details set out above. Thank you for your prompt attention to this matter.
Yours faithfully,
________