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Online Accident Details Form

IMPORTANT

To process your recovery we require the following:

Registration papers

Driver Drivers Licence

Signed Authority to Act signed by Owner

TEL: 02 9958 2407
EMAIL: claims@elmassianlawyers.com.au

Repairer Details

Repairer Name *

Repairer Phone *

Not At Fault Party Details (Your Car)

Driver

Driver's Title *

Mr
Ms
Mrs

Driver's Name *

Driver's Email *

Driver's Phone *

Driver's Address *

Driver's Suburb *

Driver's Postcode *

Registered Car Owner

Car Owner's Title *

Mr
Ms
Mrs

Car Owner's Name *

Car Owner's Email *

Car Owner's Phone *

Car Owner's Address *

Car Owner's Suburb *

Car Owner's Postcode *

Vehicle Details

Your Vehicle Make *

Your Vehicle Model *

Your Vehicle Year *

Your Vehicle Reg No. *

Insurance Details

Insurance Company Name *

Insurance Cover *

Your Vehicle Year
Third Party
None

Hire Car Required? *

Yes
No

Replacement Car Company Used

At Fault Party Details (Other Car)

Driver

Other Driver's Title *

Mr
Mrs
Ms

Other Driver's Name *

Other Driver's Email

Other Driver's Phone *

Other Driver's Address *

Other Driver's Suburb *

Other Driver's Postcode *

Other Driver's Licence Number *

Registered Car Owner (Other Car)

Other Car Owner's Title *

Mr
Mrs
Ms

Other Car Owner's Name *

Other Car Owner's Email

Other Car Owner's Phone *

Other Car Owner's Address *

Other Car Owner's Suburb *

Other Car Owner's Postcode *

Other Car Details

Other Car's Make *

Other Car's Model *

Other Car's Year *

Other Car's Reg No *

Other Driver's Insurance Details

Other Driver's Insurance Company *

Other Driver's Insurance Cover *

Comprehensive
Third Party
None

Insurance Company Phone *

Claim Number *

Witnesses

Witness Name

Witness Email

Witness Address

Witness Phone

Accident Details

Weather Condtions

Dry
Wet
Raining

Date of Accident *

Traffic Conditions

Light
Moderate
Heavy

Time of Accident *

No. of Vehicles Involved *

Place of Accident - Street *

Place of Accident - Suburb *

Accident Description

Please give a full details description of what happened including cross streets, number of lanes each way, vehicle lane you were in, traffic signals, speed you were doing, moving or stationary):

Draw diagram of accident using:

A = Not at fault car (your car)
B = At fault car
C = Any other car’s involved

Then upload the file here:

File Upload

Drop your file here or click here to upload

Injuries

Has the driver or passenger(s) been injured? *

Yes
No

Police Report

Did Police Attend? *

Yes
No

Was the matter reported to the police? *

Yes
No

Police Report/Event Number

Date Incident Reported

Police Officer's Name

Station

Was Anybody Booked? *

Yes
No

If yes, charged with:

Email: info@elmassianlawyers.com.au

Call us: 02 9958 2407