- ACCIDENT REPLACEMENT VEHICLE-RECOVERY FORM -

CITY MOTOR TRANSPORT INSURANCE SERVICES (CMT)

COMMERCIAL & PRIVATE INQUIRY AGENT

 
Details of your vehicle and insurance details
Drivers Full Name: Date of Birth:
Owners Name:
Address: Post Code:
Phone (business): Phone (after hrs):
Owners Insurance Co: Policy/Claim No:
Drivers Licence: Expiry Date:
Type of Cover:
Green Slip TTP Comprehensive
Vehicle Type: Year of Manuf:
Vehicle Model: Registration No:
Details of the party at fault
Drivers Full Name: Date of Birth:
Owners Name:
Address: Post Code:
Phone (business): Phone (after hrs):
Owners Insurance Co: Policy/Claim No:
Drivers Licence: Expiry Date:
Type of Cover:
Green Slip TTP Comprehensive
Vehicle Type: Year of Manuf:
Vehicle Model: Registration No:
Details of the accident
Date of Accident: Time:
Suburb:
Location:
Nearest Cross Street:
Name & Address of Witness:
Brief description of accident:
No of vehicles involved:
Smash Repairer
please fax or post us a copy of repair quote, (our Contact Details).
Name of Smash Repair:
Phone Number: Fax Number:
Date Vehicle Inspected: Date Repair Authorised:
Date Repair Commenced: Is you vehicle drivable?
Details of the report to the Police
Please fax or post the police report if available, (our Contact details).
Did the Police attend: What charges did the police lay:
Was anybody fined: Officer's Name:
Report Ref No: Police Station:
When do you require Credit Rentals?
What is your occupation:
What is the reason for hiring the vehicle:
Kms/day (40 Kms/day min):
What day/s do you work:
What hours do you work:
Was a courtesy car available:
Did you have any other option (eg. 2nd family car):
Travel destination to and from:
Were other forms of public transport available to your required destination:
If no, why not:
Declaration and Authorisation

 

I/We authorise CMT to act as my/our agent to organise the hire of a replacement vehicle for my/our use while my vehicle is being repaired/replaced. I/we also authorise CMT to act to recover the costs of the hire of that replacement vehicle, and if necessary to instruct solicitors to act in my/our name to recover such hire costs, including commencing legal proceedings if required.
The hirer acknowledges and agrees that:
CMT may initially pay the hire costs on my/our behalf. In that event that CMT does not recover such costs the hirer is liable to reimburse CMT for that expense. In the event that CMT is successful in recovering the hirer costs on behalf of the hirer, and if CMT have made a payment to the hire company on the hirer's behalf then the hirer authorises CMT to receive all sums recovered from the third party (or it's insurer) as repayment for such hire costs.
CMT discloses and hirer acknowledges that CMT may receive a commission on the hire costs from the car hire company.
Authorise CMT to act as my/our agent to recover the costs of the repair to the damaged property, and if necessary to instruct solicitors to act in my/our behalf to recover such costs, including commercial legal proceedings, if required. I/we also authorise CMT to act as my/our agent to appoint a loss assessor to assess the damage to my/our property. I/we also authorise CMT to pay the repairer the cost of the repair referable to the property damage. I/we also authorise CMT to sign releases on my/our behalf in relation to property damage and all other required documents associated with property damage.
The customer acknowledges and agrees that:
CMT discloses and the customer acknowledges that CMT may receive a commission on the costs recovered from property damage.

 
Name: Date:

Please fax us on: +(612) 9362 1360 or post to:

City Motor Transport Insurance Services

P.O.Box 1301, Double Bay NSW 1360

a copy of your driver's license and car registration certificate

Phone: Australia Freecall - 1 300 887 712