Spaceships Vehicle Claim Form

Insured Details
Vehicle Details
Details of Driver/Operator/Person in Charge of Vehicle

(If No, please provide further detail)

(If Yes, please provide further detail)

(If Yes please provide the Officers name and Station)

(If Yes, please provide further detail)

(If Yes, please provide further detail)

(If Yes, please provide further detail)

Details of the Accident

Where did it happen?

When did it happen?

(If Other Driver, please state why)

Details of Damage to the Vehicle

Please provide a brief description of the damage that has occurred to the vehicle:

Please also indicate where damage has occurred on the diagram:

Where is the vehicle now?:

Details of the other party involved in the accident

(If Yes please provide further detail)

Vehicle Details:

Details of any Passengers
Details of any Independent Witnesses
Declaration

Pusuant to the PRIVACY ACT 1993 the following is brought to you attention

(a) This claim form collects personal information about you
(b) The information is collectd to evaluate your claim
(c) The collection of this information is required pursuant to the terms of your insurance policy;
(d) The failure to provide this information may result in your claim being declined;
(e) You have the rights ti access to, and correction of, this information subject to the provisions of the Privacy Act 1993

DECLARATION: Note: Failure to provide full and truthful information could result in the claim being declined

I/We declare that the information given in this form is correct.
I/We authorise and request the Australian Police to release Spacehips Australia copies of any documents held by the Australian Police relating to the incident giving rise to this claim. If necessary, authorityshould be treated as a formal request pursuant to the Official Information Act, 1982.
I/We authorise the disclosure of personal information held by any other party regarding this claim.
I/We agree to Spaceships Australia releasing to other parties personal information regarding this claim.

I HAVE READ THE ABOVE & DECLARE THAT TO THE BEST OF MY KNOWLEDGE THE ANSWERS PROVIDED IN THIS FORM ARE TRUTHFUL

Name of the person who completed this form:

Accident Diagram

Please draw a sketch showing the position of all vehicles and pedestrians at the time of the accident. Show also the position of traffic lights, signs, how many lanes of traffic in both directions and pedestrian crissings.