Theft of Vehicle

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.
Policy Number(Required)
Contact Full name(Required)
First Last
Contact Number(Required)
Australia+61
7 1234 7896
Mobile Number
Australia+61
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

Details of the incident
Describe how the theft occurred(Required)
0 of 500 max characters
Date of incident(Required)
DD slash MM slash YYYY
Time of incident(Required)

: Hours

Minutes

AM/PM

Where did the incident occur?
Address(Required)
Street Address City State Postcode Country

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}
Details of the incident
Describe how the theft occurred	{:38}
Date of incident	{:39}
Time of incident	{:40}
Where did the incident occur?
Address	{:43.1}, {:43.3}, {:43.4}, {:43.5}, {:43.6}
Witness Details
Were there any witnesses to this incident?	{:54}
Other witness details	{:55}
Has the incident been reported to the police	{:78}
Please advise the police report number	{:79}

Privacy

The Privacy Act 1988 requires us to tell you that as an insurance broker we collect your personal and sensitive information in order to calculate your loss and entitlements and handle claims. When handling claims we may have to disclose your personal and other information to third parties such as other insurers, loss adjusters, investigators and agents or other parties as required by law. You have the right to seek access to your personal information and to correct it at any time. Please contact us on 1300 655 037 EST 9am-5pm Mon - Fri and advise us of the changes.
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
Email
This field is for validation purposes and should be left unchanged.

Step 1 of 8 - Your Details

Privacy

Vehicle Details

Driver Details

If the driver is not the insured owner, please state

Details of the incident

Where did the incident occur?

Witness Details

Your Details

Vehicle Details

Driver Details

Details of the incident

Where did the incident occur?

Witness Details

Privacy