Accident Claim Form

Policy Holder / Member’s Details

Full Name*(Required)

Address*(Required)

State*(Required)

Post Code*(Required)

Company Name (if applicable)

Contact No.*(Required)

Email

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Member’s Vehicle (Taxi)

Vehicle Information

Year*(Required)

Make*(Required)

Model*(Required)

Registration Number*(Required)

Registered State*(Required)

Engine No.

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The Accident

Sketch and upload a clear diagram of the accident (to be completed by driver)*. Show positions of vehicles or obstacles involved. Mark names of roads. Follow the instructions detailed here.
To upload, draw your sketch and take a photo. Save this photo to your computer (if using). Click the ‘Choose file’ button and select the image from your files.

File Upload(Required)

Max. file size: 300 MB.

Date of accident*(Required)

Day of accident*(Required)

Place of accident

Name of street travelling in*(Required)

If at intersection, name of intersecting street

Suburb or town*(Required)

Driver’s statement of how accident occurred*(Required)

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Taxi Driver Details

Driver's Name*(Required)

Date of birth*(Required)

Driver's Address*(Required)

State*(Required)

Post Code*(Required)

Driver's Contact No.*(Required)

Email

Current Licence No.*(Required)

Current Licence No. of years held*(Required)

Current Taxi Authority Licence No.*(Required)

Current Taxi Authority Licence No. of years held*(Required)

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Other Party’s details

Other Party Driver's Name

Other Party Phone No.

Other Party Driver's Address

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Witness Details

If there were any witnesses complete this section:

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Police Details

If the accident was attended by/reported to the police complete this section:

Name of Officer

Name of Station

Phone No.

Police Report No.

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Your Vehicle (Taxi)

Name of the towing company

If you have been provided a towing invoice, please upload it here:

Max. file size: 300 MB.

If yes, where is your vehicle?

Important please note: No repairs to damaged vehicle are to be made until authorised by the company.
If you have images or photos from the scene of the incident upload them here.

Images of cars at the scene and or the cars involved

Drop files here or

Max. file size: 300 MB.

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Declaration

To be completed by driver:

Driver Declaration Full name*(Required)

of

Driver Declaration Address*(Required)

Do solemnly and sincerely declare that the details and information provided are true and correct and were completed by myself, I promise to assist Taxicare in every way in dealing with the claim.
I agree to my details being provided to any other parties.
I declare that no information has been withheld which may affect the claim.
I agree and understand to all of the above

Driver Declaration Date*(Required)

Driver's Signature*(Required)

To be completed by the owner:

I/We,

Owner Declaration Full Name

of

Owner Declaration Address

Do solemnly and sincerely declare that
1. The particulars contained in the claim form relating to the driver are true and correct to the best of my knowledge and belief and I promise to assist Taxicare in every way in dealing with this claim.
2. I / We declare that no information has been withheld which may affect the claim.
I / We confirm that Taxicare may at their own discretion instruct any solicitor to act in our common interest in respect of any claim or proceedings as Taxicare may consider desirable in our common interest or in Taxicare’ s own interest.
I / We hereby claim indemnity under my / our policy in respect to this accident or loss and authorise the repairer approved by Taxicare to carry out repairs and to accept the appointment of any assessor instructed by Taxicare.

Owner Declaration Date

Owner's Signature

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Owner Authority To Act

I/We

Authority to Act Member name / Company

appoint Taxicare Australia to act on my/our behalf in dealing with all aspects in claim related matters.

I authorise Taxicare Australia to receive all payments but not limited too: Repairs/Tows/assessments and any other claims related losses.

Authority to Act Owner Signature

Authority to Act Date

Authority to Act Full name

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Email

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