mobile plant claim form
1. Your Details
3. Incident Details
Policy Number
Date of Incident
Time
am / pm
Name of Insured
Address and place where incident occurred
Contact Person
Please advise in detail how the incident occurred and who caused the
damage. Please add more information in Section 7 if needed.
Postal Address
Telephone
Mobile
Email
Are you entitled to claim back the GST component of costs relating to
the insured property, as an Input Tax Credit from the ATO?
NO
YES 100%
YES OTHER %
Please draw a plan of the accident. Show the nearest landworks and
movement of plant.
Indicate your plant as
If Yes, what is your ABN?
EFT Details:
Bank
Branch
BSB
Account Number
A
Indicate any other plant as
B
Account Name
2. Insured Plant
Is the plant you are claiming for under a financial agreement (eg
mortgage or lease)?
NO
YES, Owner
Speed of OTHER plant at the time of accident
Registration / Asset No.
Manufacturer & Model
Year
Specifications
Type and weight of load
YES
Speed of YOUR plant at the time of accident
Is this plant Hired In?
NO
NO
Was your plant damaged?
YES, Financier
Time journey commenced
am / pm
Place journey commenced
Destination
NOTES: The issue or acceptance of this claim form is not be construed as an admission of liability. This claim form does not constitute or imply acceptance of this claim. Bank
account details are collected for the purpose of making a claim payment in the event that a claim settlement is payable to you. Your bank account details will be provided to
the relevant Insurer and financial institution and will not be disclosed to any other party unless authorised or required by law. No responsibility will be taken if the bank account
details provided are incorrect.
Phone: 08 9214 7400
Email: [email protected]
Web: ckarisksolutions.com
mobile plant
4. Driver / Operator Details
Inbound or outbound to home base?
Weather and ground conditions
mobile plant
Inbound
Outbound
Please describe the damage to your plant
For parked or unattended plant, driver = plant custodian at the time of loss
Name
Date reported
Class
No. Years Licensed for
this type of machine
A PHOTOCOPY OF BOTH SIDES OF LICENCE MUST BE ATTACHED
Operators Ticket details (Please attach)
Are you the owner of the plant?
NO
YES
Was the plant driven without the Insured’s
consent?
NO
YES
Was any intoxicating liquor or drugs (including
prescription drugs) consumed in the 12 hours
preceding the accident or transit journey?
NO
YES
Did you undergo a breath or blood test for
alcohol or drugs?
NO
If No, please state your relationship to the
owner
YES
If yes, please state how much, when and results
Station or Officer
PLEASE KEEP US INFORMED OF ANY POLICE PROCEEDINGS
WHICH MAY OCCUR.
7. History
Have your or the Driver/Operator had any
insurance or renewal of insurance declined or
cancelled or special conditions imposed in the
last five (5) years?
NO
YES
Have you or the Driver/Operator had an accident
or made a claim on a motor vehicle insurance
policy in the last five (5) years?
NO
YES
Have you or the Driver/Operator been convicted
of or had any fines or penalties imposed for any
driving offence (such as speeding, disobey traffic
lights etc) in the last five (5) years?
NO
YES
Have you or the Driver/Operator been convicted
of or had any fines or penalties imposed for any
criminal offence?
NO
If yes, please state how much, when and results
Is your plant still drivable?
NO
YES
Was your plant towed away?
NO
YES
If yes, who towed your plant?
Have you obtained a repair quote?
Did you refuse to undergo any of the above
tests?
NO
YES
NO
YES
I/we certify that the information given in this form is truthful,
accurate and complete. No information likely to affect this claim
has been withheld.
I/we understand that this claim may be refused if information is
untrue, inaccurate or concealed.
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Date
YES
If any other parties were involved, who do you consider responsible for
the incident and why?
NO
YES
9. Declaration
8.
Signature of DRIVER/OPERATOR
5. Other Parties and Witnesses
If yes, where is it currently located?
If applicable, please provide any other information relevant to this claim
Have any charges been laid or any Police action taken or initiated?
Date of Birth
Drivers Licence No Expiry Date
Please show the damaged areas to your plant
We cannot proceed with claims for theft or malicious damage without the
following details:
Police Report Number or Online Crash Report Lodgement Number
Address
Telephone
8. Other Information
7.
6. Police
Name
Position
Who is your preferred repairer?
Has any claim been made against you?
If Yes, please provide details
Phone: 08 9214 7400
Signature of INSURED
ALL known details of other parties involved and witnesses
Driver
Owner
Address
Vehicle Rego
Vehicle Model
Insurer
License No
Phone No
Email
Email: [email protected]
Name
Clear Form
Web: ckarisksolutions.com
ABN: 33 109 033 123
AFS: 276915
Date
Position
Print Form
Email Form