Accident Report Form

Please fill out this form with accurate details about the accident. All required fields must be completed to process your claim.

Vehicle Registration

Vehicle Registration Number

Enter the vehicle registration number. If it exists in our system, driver details will be auto-filled.

Vehicle Details

Current Kilometer's Reading*

Driver Details

Name*

License Number*

License Type*

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Date of Birth*

Phone Number*

Email*

Address*

City / Suburb*

State / Province*

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Postal Code*

Was the driver under the influence of alcohol/drugs in the last 48 hours?*

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Is the driver the owner of the vehicle?*

Select an option

Driver License Photos (Front & Back)*

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Upload clear photos of the front and back of the driver's license

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Supported: JPG, PNG, HEIC

Max: 10MB per photo

PTD Documents*

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Upload Permit to Drive (PTD) documents

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Supported: JPG, PNG, PDF, DOCX

Max: 10MB per photo

Vehicle Registration Documents*

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Upload vehicle registration documents

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Supported: JPG, PNG, HEIC

Max: 10MB per photo

Accident Details

Date of Accident*

Time (HH:MM AM/PM)*

Location*

Intersection Details*

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Road Surface/Conditions*

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Number of Vehicles Involved*

Accident Description*

Who do you think was responsible for the accident?*

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Was Liability admitted by either yourself or third party?*

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Did any Emergency Service attend the Scene?*

Select options

Did you report the Incident to Police?*

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Upload Your Vehicle Photos*

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Upload clear photos of your vehicle damage

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Supported: JPG, PNG, HEIC

Max: 10MB per photo

Third Party Details

Name*

Address*

Phone Number*

Driver License Number*

Date of Birth*

Email Address

Insurance Company Details

Policy Number

Claim Number

Third Party Vehicle Details

Make*

Model*

Rego Number*

Was the Vehicle Drivable?*

Select an option

Third Party Vehicle Photos*

Drop photos here or browse

Upload photos of the third party vehicle

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Supported: JPG, PNG, HEIC

Max: 10MB per photo

Details Of Any Witness (Optional - Up to 5)

No witnesses added yet. Click 'Add Witness' to add witness details.

Declaration

I Declare that all details provided are true and correct and I further declare that I have not withheld any Information. I also declare and give full authority to Fleetsaver Service Inc., its authorized panel beaters, Insure Panel Pty Ltd, Budget Panel and Paint and other services or businesses authorized or engaged by Fleetsaver Service Inc. to act on my behalf, represent me, to receive payments for the services provided including, towing, rental vehicles, loss of income/use, and arrange and engage with other businesses, 3rd party or their insurance company to process my vehicle accident claim, recover their repair costs or any other associated costs for this accident or any other future accidents or claims.

Form Filler Name*

Digital Signature*

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