Insurance Claim FormGT Insurance Policy CPG20206919

Last Updated: 18/08/2020Page 1 of 2Alliance Leasing

Email completed claim form along with any other supporting documentation to jake.lee@gtins.com.au(Claims Consultant, GT Insurance)

Contact name

Contact Details Mobile

Email

Date of Incident

Time of Incident

Location of Incident

Vehicle details Make/Model Rego

Year VIN

If you have photos of your vehicle and/or the third party vehicle, please email with this claim form

Current location of your vehicle

Do you have dashcam footage of the incident

Describe damage to your vehicle

Your vehicle-Driver details

Name DOB

Licence Number Number of years licensed

Licence Class Is the licencecurrent?

Alcohol or Drugs Were drugs or alcohol consumed in the previous 12 hours?

Breathalyser / Blood test taken:

Police Did police attend the incident?

Police Report Number

Insurance Claim FormGT Insurance Policy CPG20206919

Insurance Claim FormGT Insurance Policy CPG20206919

Third Party Details

Name of Owner

Name of Driver

Address of Driver

Make/Model

Rego Number

Third party vehicle insurer

Describe damage to third party vehicle/property

**Full incident Description Required**Detailed Incident description

Diagram

Last Updated: 18/08/2020Page 2 of 2Alliance Leasing

* Please save and download this form if completing itwithin the web browser to use the Submit Form Button. Alternatively you may save the completed form and email it directly to jake.lee@gtins.com.au.