Claim Form

Full name of registered owner of the vehicle

Mrs

Miss

Full Name

Family Name

Address

Telephone

Email address

Occupation

License Number

Registered for GST?

Yes

ABN

Was someone else driving your vehicle at the time of the incident?

Yes

If yes, please fill in driver details below or skip to next section.

Driver details

Mrs

Miss

Name

Telephone

Address

What is the relationship to the owner?

Your vehicle

The Accident

Date of accident

Time

Location (road or street)

Suburb/Town

Explain how the accident occurred

At the time of the accident, the speed of your vehicle (kmh)

At the time of the accident, the speed of the other vehicle (kmh)

Who in your opinion was responsible for the accident?

Upload diagram of your accident

Personal Items

Particularise below any items which were damaged or destroyed as a result of the collision (including baby seats/riding gear):

At Fault Party Details

It is most important that the details here are accurate - eg the full name or at least initials of the actual driver of the other vehicle.

Injuries

Kenyon and Ahmet Lawyers do not act in personal injury claims.

Were you or any other person in your vehicle injured?

Yes

If so, would you like us to provide a referral to you to a specialist personal injury lawyer?

Yes

Police

The Law compels a report to the police if anyone involved was injured, proper details not fully exchanged or property owner not present.

Was the collision reported to the police?

Yes

If yes, details of police:

Has either driver been charged?

Yes

Unsure

Was a breathalyzer test carried out?

Yes

Unsure

If yes, result:

Witnesses & Passengers

Were there any passengers in your vehicle?

Yes

Were there any independent witnesses to the collision

Yes

If yes, the names and addresses of the witness/witnesses:

I authorise Kenyon & Ahmet Lawyers of Suite 6, 150 Chestnut Street, Cremorne 3121, to contact me and discuss my motor vehicle collision.
I Agree to
- Refer any contact from the other party/insurers to Kenyon & Ahmet Lawyers.
- Provide to my lawyers all reasonable assistance and co-operation in relation to these instructions.
- Notify Kenyon & Ahmet Lawyers of any change of address by me and confirm that should I fail to do so, they are entitled to consider themselves no longer bound by my instructions.
I acknowledge that Kenyon & Ahmet Lawyers are relying upon the information supplied by me as to the circumstances and particulars surrounding the collision

I Agree