Vehicle Incident Report - Chemo At Home

Insured

View health - Chemo@home - 241 Fitzgerald Street, West Perth 6005, WA - 1300 466 324

Insured Vehicle *

First

Middle

Last

Name *

First

Last

Class of Vehicle: *

Sedan or Station Wagon
Van or Utility up to 2T
Four Wheel Drive

What was intended operating radius of the journey? *

State the time and place journey commenced, as well as the intended destination: *

State type and weight of goods being carried? *

Driver Details: *

First

Last

Date of Birth: *

Address: *

Address Line 1

City

State / Province / Region

Postal Code

Country

Current Driver's Licence number and endorsments: *

First

Last

Name of registered owner of the vehicle: *

Are you an employee? *

Yes
No

Have you had any traffic convictions and/or traffic offences or been involved in any motor vehicle accidents in the past five (5) years? *

Yes
No

If 'Yes' please give details:

How many hours have you spent driving in the 48 hours immediately preceding the accident? *

Did you consume any alcohol or take any drugs during the 12 hours prior to the accident? *

Yes
No

If 'Yes' state what, how much and when:

Did you undergo a breath test or blood test for alcohol or drugs? *

Yes
No

If 'Yes' what was the result:

Did you refuse to undergo any of the above tests? *

Yes
No

Was your vehicle damaged? *

Yes
No

If tyres damaged, approximate mileage of tyres:

Was your vehicle towed away? *

Yes
No

If 'Yes' provide the name of the towing company:

Have you obtained 2 repair quotes? *

Yes
No

Lowest quote: *

Who is your preferred repairer? *

Is the vehicle there? *

Yes
No

If 'No' where is the vehicle located? (provide the full address)

Address Line 1

City

State / Province / Region

Postal Code

Country

Please provide any photos of the damaged areas on the vehicle: *

Drag & Drop Files, Choose Files to Upload You can upload up to 10 files.

Date / Time *

Date

Time

Location:

Address Line 1

City

State / Province / Region

Postal Code

Country

How did the incident or theft happen? *

Who do you consider was at fault? *

Myself
Other Driver

Please explain why: *

Estimated speed of your vehicle 30 meters prior to accident?

Estimated speed of your vehicle at impact? *

Estimated speed of the other vehicle just before the accident? *

What lights if any were being used by you?

What lights if any were being used by the other party? *

What signals were given by you? *

What signals were given by the other party? *

How far from the point of collision were you when you first saw the other party? *

How far from the point of collision was the other party when first seen by you? *

How was visibility? *

Good
Moderate
Poor

Police Questions

Did police attend the accident? *

Yes
No

Police Report Number:

If 'Yes' please provide the Police Station and the name or number of Police officer:

If 'No' state time and date reported to Police

Did the police indicate who was responsible? *

Yes
No

If 'Yes' name of driver?

Did police charge either driver or suggest action may be taken later? *

Yes
No
Charge

Damage to other Vehicles or Property

Please provide the following details

Name of Other Driver *

First

Last

Address: *

Address Line 1

City

State / Province / Region

Postal Code

Age: *

Phone Number: *

License Number: *

Vehicle Details: *

First

Middle

Last

Name of Registered Owner: *

Address: *

Address Line 1

City

State / Province / Region

Postal Code

Country

The other insurance company: *

Policy number: *

Description of Damage: *

Personal Injuries

Was anyone injured in the accident? *

Yes
No

If 'Yes' what is the name of the person injured?

What type of injury is it?

Injury party?

Driver
Passenger

DECLARTATION:

By submitting this form, I declare that:

(a)The information and answers given above are true in every details and no information has been withheld or misrepresented.

(b)Chemo at Home has authority to move the vehicle to ensure safekeeping.

Name: *

First

Last

Date: *