Mercurien Insurance – Mercurien is an organisation that protects people and assets in the mobile workplace.

What is your policy number?

Date of Loss(Required)

Day

Month

Year

Time(Required)

Cause Of Loss(Required)

Are you registered for GST?(Required)

Yes

ITC entitlement

Please provide details of the person driving the vehicle at the time of the incident(Required)

First Name Last Name

Email(Required)

Phone(Required)

License No(Required)

License Expiry(Required)

Day

Month

Year

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Policy Holder details

Same as the drivers details

Name(Required)

First Last

Email(Required)

Phone(Required)

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Main Claim Contact(Required)

Date of Birth

Day

Month

Year

Details of the vehicle insured under this policy?

Registration number

Make

Model

Year of Manufacture

Is the insured vehicle a rented vehicle?(Required)

Yes

What service was being performed when the incident occurred?(Required)

Private

Business

Recreational

Is the vehicle currently under finance or encumbered?(Required)

Yes

Please provide finance details if you have them

Name of financial institution(Required)

Outstanding loan amount

When did the incident occur?

Date(Required)

Day

Month

Year

Time(Required)

Where did the incident occur?

Street Address City State Postcode Country

Incident details

Please describe the incident in your own words(Required)

Was the vehicle parked when the incident occurred?(Required)

Parked

I was driving

Which best describes the cause of the incident?(Required)

Single vehicle incident

Weather of natural occurrence

Malicious damage

Theft or attempted theft

Another vehicle hit me

I hit another vehicle or vehicles

Has this incident been reported to the police?(Required)

Yes

Were there any witnesses to the incident?(Required)

Yes

Please provide any pictures or camera footage available

Drop files here or

Max. file size: 2 MB.

Please List which areas of your vehicle were damaged

Damage description

Please describe the damage(Required)

Please upload any pictures and/or videos of the damage

Drop files here or

Max. file size: 2 MB.

Who do you suspect caused the accident?(Required)

The other driver

Someone else

Please provide details of the other driver and vehicle if known

Name

First Last

Email address

Phone

Registration number

Address

Street Address City State Postcode Country

If known, please provide the other driver's insurer details

Insurer name

Claim number

Is your vehicle safe to drive?(Required)

Yes

Has the vehicle been repaired already?(Required)

Yes

What is the date of birth of the driver?

Month

Day

Year

What year did the driver start driving in Australia?

Have you had any motor insurance claims in the past 3 years?(Required)

Yes

Do you currently have any demerit points on your licence?(Required)

Yes

Details

How many?

For what offences?

Declaration agreed?(Required)

Please confirm the following with the insured or their representative

On behalf of the insured, I declare the above answers to be true and correct in every particular and acknowledge that Mercurien Insurance Pty Ltd and Assetinsure Pty Ltd may make their decision on indemnity having regard to these answers.

I consent to Mercurien Insurance Pty Ltd and Assetinsure Pty Ltd using the personal information which I have provided on this form for the purposes of processing this claim. I understand that if I choose not to provide the required details, Mercurien Insurance Pty Ltd and Assetinsure Pty Ltd may not be able to process this claim.

I consent to Mercurien Insurance Pty Ltd and Assetinsure Pty Ltd disclosing my personal information to other insurers, an insurance reference service or as required by law. I also consent to Mercurien Insurance Pty Ltd and Assetinsure Pty Ltd disclosing my personal information to, and/or collecting information about me from, third parties such as investigators or legal advisers

Where I have provided information about another individual (for example an employee or client), I declare that the individual has or will be made aware of that fact. Please select to confirm.

Additional info:

Full name(Required)

Date(Required)

DD slash MM slash YYYY

Signature(Required)

Phone

This field is for validation purposes and should be left unchanged.