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Please complete the following online form to submit your motor vehicle insurance claim;

Motor Vehicle Claims Advice Form

Your Name:(*)
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Your Contact Phone Number:(*)
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Your email:(*)
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Client code:
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Policy Number:
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INSURED
Your Business' ABN:
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INSURED VEHICLE
Make & Model:(*)
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Type of Vehicle:(*)
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Year:(*)
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Rego No:(*)
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ACCIDENT DETAILS
Date (dd/mm/yyyy):(*)
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Time (please include am or pm):(*)
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Location:(*)
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How did the accident happen?(*)
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DRIVER
Name:(*)
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Address:(*)
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DOB:(*)
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Licence No:(*)
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Expiry Date (dd/mm/yyyy):(*)
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Years Licenced:(*)
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Any traffic convictions / Criminal offences / Policies cancelled within the past five years / or been involved in any motor accidents in the past five years?
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If Yes, please give details:
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Did you consume any alcohol / drugs 12 hours before the accident?(*)
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Did you undergo a breath test / blood test for alcohol or drugs?(*)
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Did you refuse to undergo either test?(*)
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Were there any witnesses?(*)
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If Yes, please provide name and contact details for the witness(es):
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Did police attend?(*)
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If Yes, please provide the name of the police station and the name or number of the attending police officer:
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DAMAGE TO OTHER VEHICLE OR PROPERTY
Name of Other Driver:
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Phone No:
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Address:
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Vehicle Make & Model:
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Rego:
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Preferred Repairer:

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LEA Life Brokers Pty Ltd AR No. 289102
Is a Corporate Authorised Representative of
Millennium3 Financial Services Pty Ltd
ABN 61 094 529 987 Australian Financial Services
Licensee – Licence Number 244252
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Address: 47 Ashmore Road, Bundall QLD 4217
Phone: (07) 5538 8988

LEA Insurance Brokers Pty Ltd AFSL No. 241418
ABN 58 523 762 917
Home | Privacy Policy | Financial Services Guide
Site Map | Contact Us
Address: 47 Ashmore Road, Bundall QLD 4217
Phone: (07) 5538 8988


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