Accident with another vehicle

Privacy(Required)
The Privacy Act 1988 requires us to make the following disclosure before collecting personal information about you:

We collect personal information in order to provide our broking services, including assistance with insurance claims.

We will ask you to supply personal information on this form so we can assist you to submit your insurance claim, and have it considered by the insurer. We will disclose this information to the insurer for this purpose.

If the personal information is not provided, the insurer may not be able to assess and pay the claim and we may not be able to assist with your claim.

We and the insurer may disclose the personal information to other people involved in reviewing the claim, including reinsurers, other insurance intermediaries, the insurer's advisors such as loss adjusters, lawyers and accountants, and other parties involved in the claims handling process.

Your information will be disclosed to organisations overseas if your policy is underwritten by an overseas insurer. The Privacy Act and Australian Privacy Principles may not apply to these organisations.

By completing this form, you consent to us, and the parties mentioned above collecting, using, and disclosing personal and sensitive information about you for the purposes described above. You understand that any personal and sensitive information disclosed to organisations located overseas may not be protected in the same way as it is in Australia.

Even though we have no control over how the information will be used and disclosed, you consent to us disclosing your personal and sensitive information to those overseas organisations for the purposes described above.

Further information about how to access, update and/or correct the personal information we hold about you, and how to make a complaint, is within our Privacy Policy available on our website: www.networksteadfast.com.au/privacy-statement. You can also contact our Privacy Officer at privacyofficer@networksteadfast.com.au.
- I agree
Privacy

The Privacy Act 1988 requires us to make the following disclosure before collecting personal information about you:

We collect personal information in order to provide our broking services, including assistance with insurance claims.

We will ask you to supply personal information on this form so we can assist you to submit your insurance claim, and have it considered by the insurer. We will disclose this information to the insurer for this purpose.

If the personal information is not provided, the insurer may not be able to assess and pay the claim and we may not be able to assist with your claim.

We and the insurer may disclose the personal information to other people involved in reviewing the claim, including reinsurers, other insurance intermediaries, the insurer's advisors such as loss adjusters, lawyers and accountants, and other parties involved in the claims handling process.

Your information will be disclosed to organisations overseas if your policy is underwritten by an overseas insurer. The Privacy Act and Australian Privacy Principles may not apply to these organisations.

By completing this form, you consent to us, and the parties mentioned above collecting, using, and disclosing personal and sensitive information about you for the purposes described above. You understand that any personal and sensitive information disclosed to organisations located overseas may not be protected in the same way as it is in Australia.

Even though we have no control over how the information will be used and disclosed, you consent to us disclosing your personal and sensitive information to those overseas organisations for the purposes described above.

Further information about how to access, update and/or correct the personal information we hold about you, and how to make a complaint, is within our Privacy Policy available on our website: www.networksteadfast.com.au/privacy-statement. You can also contact our Privacy Officer at privacyofficer@networksteadfast.com.au.
- Click here to download a vehicle panel damage diagram.
- Use this diagram to depict where there is damage to your vehicle by clearly shading the area affected
Policy Number(Required)
Contact Full name(Required)
First Last
Contact Number(Required)
7 1234 7896
Mobile Number
420 123 456
Name of insured / Company Name(Required)
Is the insured the registered owner(Required)
- Yes
- No
Name of registered owner(Required)
Are you registered for GST(Required)
- Yes
- No
If you are eligible to claim an Input Tax Credit (ITC) for the Items(s) that you are making a claim for, you will need to provide us with your full Australian Business Number and the percentage of ITC that you are entitled. If you are unsure of your ITC %, you can check this with your accountant.
What is your ABN Number(Required)
What is the format of the ABN? The Australian Business Number (ABN) is a unique 11 digit identifier issued to all entities registered in the Australian Business Register (ABR). The 11 digit ABN is structured as a 9 digit identifier with two leading check digits.
To what extent are you entitled to claim an input tax credit on the GST for this policy?(Required)
Please advise your percentage %
Please advise your ITC percentage as a number.

Vehicle Details
Year of manufacture
Vehicle Registration No.(Required)
Vehicle make(Required)
Vehicle model(Required)
Vehicle body type

Vehicle information
Was the vehicle used for business at the time of the incident(Required)
- Yes
- No
Was the vehicle towed(Required)
- Yes
- No
Towing company details(Required)
Has a quote been obtained(Required)
- Yes
- No
Please advise repairer's details(Required)
Do you have a quote to upload?
- Yes
- No
File upload
Drop files here or

Max. file size: 2 MB.

Details of the incident
Describe how the incident occurred(Required)
Date of incident(Required)
DD slash MM slash YYYY
Time of incident(Required)

: Hours

Minutes

AM/PM
Who, in your opinion was to blame for the incident?

Where did the incident occur?
Address(Required)
Street Address City State Postcode Country
Is there damage to your vehicle?(Required)
- Yes
- No
- Click here to download a vehicle panel damage diagram.
- Use this diagram to depict where there is damage to your vehicle by clearly shading the area affected
Upload image of vehicle damage
Drop files here or

Max. file size: 2 MB.

Details of other vehicle(s)
Owner's Name (Third Party)(Required)
First Last
Phone(Required)
7 1234 7896
Address(Required)
Street Address City State Postcode Country
Driver's licence number
Third Party Vehicle registration number
Were there other vehicles involved?(Required)
- Yes
- No
Other party details(Required)
Name Phone Third Party Vehicle Registration Number

Witness Details
Were there any witnesses to this incident?(Required)
- Yes
- No
Other witness details(Required)
Name of witness Contact details for witness
Has the incident been reported to the police(Required)
- Yes
- No
Please advise the police report number

Your Details
Policy Number	{:1}
Contact Full name	{:2.3} {:2.6}
Contact Number	{:3}
Mobile Number	{:4}
Name of insured / Company Name	{:5}
Is the insured the registered owner	{:6}
Name of registered owner	{:7}
Are you registered for GST	{:9}
What is your ABN Number	{:8}
To what extent are you entitled to claim an input tax credit on the GST for this policy?	{:66}
Vehicle Details
Year of manufacture	{:11}
Vehicle Registration No.	{:14}
Vehicle make	{:12}
Vehicle model	{:13}
Vehicle body type	{:15}
Driver Details
Driver's Full Name	{:17.3} {:17.6}
Class of Licence	{:77}
Driver's type of licence	{:18}
Has the driver had any incidents, traffic convictions and/or penalties in the last 5 Years?	{:19}
List your incidents, convictions or penalties	{:20}
Has the driver's licence ever been suspended or cancelled	{:21}
Was the vehicle being driven with the insured's knowledge or consent	{:23}
Was the driver a paid employee of the insured	{:24}
Was the driver taken to hospital	{:25}
Had the driver consumed any drugs or alcohol within 24 hours predeeding the incident	{:27}
List items consumed	{:28}
Vehicle information
Was the vehicle used for business at the time of the incident	{:30}
Was the vehicle towed	{:31}
Towing company details	{:32}
Has a quote been obtained	{:33}
Please advise repairer's details	{:34}
Do you have a quote to upload?	{:35}
File upload	{:36}
Details of the incident
Describe how the incident occurred	{:38}
Date of incident	{:39}
Time of incident	{:40}
Who, in your opinion was to blame for the incident?	{:41}
Where did the incident occur?
Address	{:43.1}, {:43.3}, {:43.4}, {:43.5}, {:43.6}
Is there damage to your vehicle?	{:63}
Uploaded image of vehicle damage	{:78}
Details of other vehicle(s)
Owner's Name (Third Party)	{:46.3} {:46.6}
Address	{:48.1}, {:48.3}, {:48.4}, {:48.5}, {:48.6}
Driver's licence number	{:49}
Third Party Vehicle registration number	{:50}
Were there other vehicles involved?	{:51}
Other party details	{:52}
Witness Details
Were there any witnesses to this incident?	{:54}
Other witness details	{:55}
Has the incident been reported to the police	{:82}
Please advise the police report number	{:83}

Claimant Declaration(Required)
By ticking this box, I/We certify that:
- The information provided in this form is truthful, accurate, and complete, with no relevant details withheld.
- It is understood that the claim may be refused if the information is untrue, inaccurate, or concealed.
- The information regarding the Privacy Act 1988 has been read and understood.
- Consent is given for the collection, storage, use, and disclosure of personal and sensitive information required for processing this claim.
- It is recognized that without this consent, Network Insurance Group will be unable to process the claim.
- The information is provided with full knowledge and consent.
- Additionally, agreement is given to indemnify and hold harmless Network Insurance Group in the event of any legal action related to the Privacy Act 1988 (Cth).
I / We certify the following
Name
This field is for validation purposes and should be left unchanged.

Step 1 of 10 - Your Details

Privacy

Vehicle Details

Driver Details

If the driver is not the insured owner, please state

Vehicle information

Details of the incident

Where did the incident occur?

Details of other vehicle(s)

Witness Details

Your Details

Vehicle Details

Driver Details

Vehicle information

Details of the incident

Where did the incident occur?

Details of other vehicle(s)

Witness Details