Simplex Insurance | Make an Insurance Claim Online

Making a Claim

If you need to make a claim on your current insurance, you can choose between completing our online insurance claims form or calling 1300 309 237 to speak to one of our friendly consultants.

Online Claim Request

Claim Type*
Please select the the type of policy that you wish to make a claim against*
- Private Motor Insurance
- Business Motor Insurance
Please select the the type of policy that you wish to make a claim against*
- Personal Insurance
- Business Insurance
PLEASE NOTE:
If this claim only relates to your vehicles window glass please phone out office on 1300 309 237 as a form may not be required.
IMPORTANT:
If you are submitting a claim for truck, mobile plant or other transport operations claim, please contact us first as an insurer specific claim form may be required.
Motor Vehicle Claim Form
Insured's Name*
First Last
Policy Number
Contact Name*
First Last
Contact Phone*
Contact Email*
Registered for GST
- Yes
- No
ABN
Input Tax Credit entitlement on premium
Input Tax Credit entitlement on property damaged
Was the vehicle being used for*
- Business use
- Personal use
Vehicle Details
Year*
Make*
Model*
Rego*
Is there any finance owing on the vehicle?*
- Yes
- No
- Unknown
Are you claiming damage for the vehicle?*
- Yes
- No
Detailed description of the damage*
Was the vehicle towed?*
- Yes
- No
Has a repair quote been obtained?*
- Yes
- No
What is the current location of the vehicle?*
Preferred repairer details*
Incident Details
Date*

Day
Month
Year
Time*

: Hours

Minutes

AM/PM
Location (street/suburb)*
Please describe what happened in the accident and why it occurred e.g. speed, traffic lights, weather*
Who does the driver consider is at fault and why?*
Driver Details
Insured Vehicle
Name*
First Last
Phone*
Email
Date of Birth*

Day
Month
Year
License No.*
License Expiry Date*

Day
Month
Year
Number of Years Licensed*
License Type*
- Learners
- Probationary
- Full
License Class
Did the driver consume alcohol/drugs/medication in the 12 hours prior to the accident?*
- Yes
- No
Please Provide Details*
Please state the nature and quantity of alcohol/drugs/medication consumed.
Have you (The policy holder) or the driver of the vehicle at the time of the incident;
Had any insurance declined or cancelled, been refused renewal of an insurance, or had special conditions imposed in the last 5 years?*
- Yes
- No
Please Provide Details*
Convicted of or had any fines or penalties imposed for any criminal offence?*
- Yes
- No
Please Provide Details*
Had an accident or made a claim on a motor insurance policy in the last 5 years?*
- Yes
- No
Please Provide Details*
Third Party Information
Was a third party vehicle involved in the accident?*
- Yes
- No
Third Party Details
Please note: Driver's full name, contact number, residential address, registration, and license number is required for not at fault accidents.
Name*
First Last
Contact Phone*
Address
Street Address City State / Province / Region Post Code Country
Insurance Company
Policy/Claim Number
License No.
rego
Year
Make
Model
Detailed description of the damage
Police Details (Officers Name/Station/Police Report No.)
Witness Details
Additional Information
Property Claim Form
Insured's Name*
First Last
Policy Number
Contact Name*
First Last
Contact Phone*
Contact Email*
Registered for GST*
- Yes
- No
ABN*
Input Tax Credit entitlement on premium
Input Tax Credit entitlement on property damaged
When did the theft, damage or loss occur?
Date*

Day
Month
Year
Time*

: Hours

Minutes

AM/PM
Address*
Where did the theft, damage or loss occur?
This property is*
- Owner Occupied
- Tenant Occupied
- Unoccupied/Vacant
- A Holiday Home
Please describe the incident*
ANY LOSS INVOLVING MALICIOUS DAMAGE, LOSS OR STOLEN PROPERTY MUST BE REPORTED TO THE POLICE.
Was the property occupied at the time of loss?*
- Yes
- No
Date last occupied*

Day
Month
Year
Do you know who is responsible for the loss, theft or damage?*
- Yes
- No
Name*
Address*
Please detail what has been lost/stolen/damaged and estimate value to repair/replace*
Particulars Amount Claimed ($)
Fusion/Power Surge Claims
Age of Motor (years)
Is the motor under warranty?
- Yes
- No
Burglary Claims
How was the building entered?
Available security to the premises
Details of any security improvements taken since the loss
Police Information
Station
Report No.
Date

Day
Month
Year
Reporting officer
If your insurer approves a cash settlement, would you like funds deposited into your bank account?
- Yes
- No
Bank Name
Account Name:
BSB No.
Account No:
History
Have you (The policy holder)
Had insurance declined, cancelled or special conditions imposed in the last 5 years?*
- Yes
- No
Please Provide Details*
Convicted of or had any fines or penalties imposed for any criminal offence?
- Yes
- No
Please Provide Details*
Had an accident or made a claim on a motor insurance policy in the last 5 years?
- Yes
- No
Please Provide Details*
Declaration
By submission of this claim for, you acknowledge and accept the following Declarations

Privacy
The Privacy Act and the Australian Privacy Principles require your insurer to tell you that they collect your personal and sensitive information in order to calculate your loss and entitlements, determine their liability, compile data and handle claims. When handling claims, they may have to disclose your personal and other information to Insurance Reference Services (IRS), etc. or other parties as required by law. By reading and acknowledging the Simplex privacy collection notice you consent for us to proceed with submitting this information to your insurer. You have to right to seek access to your personal information and to correct it at any time. Please contact us on 1300 309 237 and advise the changes.

Declaration
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. I/We acknowledge that I/We have read and understood the privacy information of all persons affected by this claim. I/We acknowledge that if I/We do not agree to the collection of this personal and sensitive information then the Insurer will be unable to process my/our claim.
Do you agree to the privacy and declaration*
- I agree
Name of person submitting form*
First Last
Would you like a copy of this form emailed to you
- Yes please
Email*

PLEASE NOTE: If you do not received this email within an hour please check your junk mail folder.

Expert advice at the right price!

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Particulars	Amount Claimed ($)

Making a Claim

If you need to make a claim on your current insurance, you can choose between completing our online insurance claims form or calling 1300 309 237 to speak to one of our friendly consultants.

Online Claim Request

Motor Vehicle Claim Form

Vehicle Details

Incident Details

Driver Details

Have you (The policy holder) or the driver of the vehicle at the time of the incident;

Third Party Information

Third Party Details

Property Claim Form

Fusion/Power Surge Claims

Burglary Claims

Police Information

History

Declaration

Expert advice at the right price!