Claim Form – TP Claims

Step 1 of 9

Your details

We'll use these to contact you about your claim.

Customer full name

Address

City

State

Post code

Step 2 of 9

Your vehicle

The car that was hit, plus its insurance and finance.

Vehicle

Make / Model

Registration

Is the vehicle drivable?

YesNo

Insurance and finance

Do you have vehicle insurance?

YesNo

Insurance type

Insurance company (optional)

If you have no insurance, would you like to proceed with a lawyer claim? (optional)

YesNo

Is the vehicle financed? (optional)

YesNo

Finance company (optional)

Repairer

Skip this if you haven't chosen a repairer yet.

Repairer name (optional)

Repairer phone (optional)

Repairer address (optional)

Step 3 of 9

The collision

When and where it happened, in your own words.

When and where

Date of collision

Time (optional)

Street

Suburb

Post code (optional)

Road condition (optional)

WetDry

Your version of the collision

Which way were you each travelling, and what did the other driver do?

Sketch of the scene (optional)

Draw the roads and where each car was, or upload a photo of a sketch on paper.

Draw with your finger or mouse

Photo of your sketch Tap to choose a file, or drag it here. JPG, PNG, HEIC or PDF, up to 10MB.

Step 4 of 9

Type of claim

Tick everything you need help with.

PAV / Repair Report Tow / Quote / Car Hire / Other PI Claim

Assessment location (optional)

Where can an assessor inspect the car? For example, your home address or the repairer.

Step 5 of 9

The at-fault driver

Whatever you swapped at the scene. Leave out anything you don't have.

At-fault driver name (optional)

Registration

Phone (optional)

Address (optional)

Insurer (optional)

Policy number (optional)

Employer (optional)

Licence sighted / copy taken? (optional)

SightedCopy takenNeither

Step 6 of 9

Passengers and witnesses

Anyone in your car, and anyone who saw it happen. Leave blank if there was no one.

Passengers

Witnesses

Step 7 of 9

Police and hire car

Police report

Only if police attended or you reported it.

Officer (optional)

Station (optional)

Date (optional)

Hire car

Do you want / intend to get a hire car? (optional)

YesNo

Hire car details (optional)

For example, the type of car you need and from when.

Step 8 of 9

Documents and photos

All optional, but they help us move faster. You can also email them to us later.

Photos of the damage and scene Tap to choose files, or drag them here. JPG, PNG, HEIC or PDF, up to 10MB each.

Your driver's licence Tap to choose a file, or drag it here. JPG, PNG, HEIC or PDF, up to 10MB.

Police report Tap to choose a file, or drag it here. JPG, PNG, HEIC or PDF, up to 10MB.

Step 9 of 9

Declaration

Read this, tick to agree, then sign by typing your name.

I DECLARE that the information I have provided in this form is true and correct. Further, I authorise Third Party Claims to contact any person regarding the accident and I authorise the solicitor acting to provide information about my matter to Third Party Claims. In addition, I understand that the principals of Third Party Claims, Your Ride Car Hire, Insurance Recoveries, Parker Quest Towing and Salvage and Vanessa Ash and My Lawyer PL are Associated. Further, I hereby indemnify Third Party Claims and its agents, officers, principals and employees against all claims and loss. There is no contract and I am barred to sue.

I have read and agree to the declaration above.

Signature (type your full name)

Date

Motor vehicle accident claim

Your details

Your vehicle

The collision

Type of claim

The at-fault driver

Passengers and witnesses

Police and hire car

Documents and photos

Declaration

Thanks — we've got your claim

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