Section 1: Contact details:

Your Name (required)

Contact Email (required)

Contact Phone (required)

Address (required)

Suburb (required)

Post Code (required)


Section 2: Insurance company details: [if required]

Insurer

Claim number


Section 3: Vehicle details:

Manufacturer [e.g. Holden]

Model [e.g. Astra]

Colour [e.g. Metallic Green]

Registration [e.g. FRM 667]

VIN Number

Paint Number

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Section 4: Vehicle damage details:

Upload image of damage – 1 (gif, png, jpg) [max file size 1MB]

Upload image of damage – 2 (gif, png, jpg) [max file size 1MB]

Upload image of damage – 3 (gif, png, jpg) [max file size 1MB]

Upload image of damage – 4 (gif, png, jpg) [max file size 1MB]

Description of damage

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