WilsonAutoam
RESERVE YOUR CAR
OUR COMMITMENT
HOW DOES IT WORK?
ABOUT US
NEWS
REVIEWS
RESERVE YOUR CAR
OUR COMMITMENT
HOW DOES IT WORK?
ABOUT US
NEWS
REVIEWS
1300 869 277
RESERVE YOUR CAR
OUR COMMITMENT
HOW DOES IT WORK?
ABOUT US
NEWS
REVIEWS
RESERVE YOUR CAR
OUR COMMITMENT
HOW DOES IT WORK?
ABOUT US
NEWS
REVIEWS
WILSON Auto Form
Contact Details
Vehicle Details
Accident Information
Insurance Details for the Vehicle
At Fault Party’s Details
At Fault Party’s Vehicle Detail
Cars Involved
Detail Description of Accident
Your Contact Details
Title:
*
Mr
Mrs
Ms
Miss
This field is required.
First name
*
This field is required.
Middle Name
Last Name
*
This field is required.
Home Address
*
This field is required.
State
*
This field is required.
Postcode
*
This field is required.
Mobile Phone
*
This field is required.
Home Phone
*
This field is required.
Work Phone
*
This field is required.
Email:
*
This field is required.
Drivers License Number and Type:
*
This field is required.
Time of Accident
Date of Accident:
*
Day of Accident:
*
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
This field is required.
Approximate Time of Accident:
*
Your Motor Vehicle
Make:
*
This field is required.
Model:
*
This field is required.
Registration Number:
*
This field is required.
Year
*
This field is required.
Colour
*
This field is required.
Accident Information
Driver of Your Vehicle (if vehicle was being driven at the time of the incident):
It was me
It wasn't me
Title:
Mr
Mrs
Ms
Miss
First name
Middle Name
Last Name
Address
Postcode
Mobile
Home Phone
Work Phone
Email:
Drivers License Number and Type:
Insurance Details for the Vehicle
Insurance Company Name:
*
This field is required.
Type of Cover:
*
Comprehensive
Third Party
This field is required.
Policy Number:
*
This field is required.
Claim Number:
*
This field is required.
Registration Papers:
(allowed file formats: docx, pdf)
Driver's License Scan Number:
(allowed file formats: docx, pdf)
At Fault Party’s Details
Details of vehicle that collided with your car:
Driver of the Vehicle
Title:
*
Mr
Mrs
Ms
Miss
This field is required.
First name
*
This field is required.
Middle Name
Last Name
*
This field is required.
Address
*
This field is required.
Postcode
*
This field is required.
Mobile
*
This field is required.
Home Phone
*
This field is required.
Work Phone
Email:
*
This field is required.
Drivers License Number and Type:
*
This field is required.
Vehicle Details
At fault party
Make:
*
This field is required.
Model:
*
This field is required.
Registration Number:
*
This field is required.
Year
*
This field is required.
Colour
*
This field is required.
Insurance Details for Vehicle at Fault
Insurance Company Name:
*
This field is required.
Type of Cover:
*
Comprehensive
Third Party
This field is required.
Policy Number:
*
This field is required.
Claim Number:
*
This field is required.
Number of other Cars Involved:
Select number of cars involved:
*
- Select -
None
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
This field is required.
Driver of the Vehicle
Car
1
:
Title:
Mr
Mrs
Ms
Miss
First name
Middle Name
Last Name
Address
Postcode
Mobile
Home Phone
Work Phone
Email:
Drivers License Number and Type:
Vehicle Details
Registration Number:
Make:
Model:
Year
Colour
Insurance Details for the Vehicle
Insurance Company Name:
Type of Cover:
Comprehensive
Third Party
Policy Number:
Claim Number:
Accident Information
Location of Accident
Street/s:
*
This field is required.
Suburb:
*
This field is required.
Is your car Drivable:
*
Yes
No
Location of damage to your vehicle:
*
This field is required.
Draw a diagram of the accident using street names and signals:
Clear
Description of Accident:
*
This field is required.
Did any party admit liability at the scene?
*
Yes
No
Details if yes
Did the police attend?
*
Yes
No
If yes displays below info
From which station did they come from?
Officers’ Names:
Police Report Number:
Were there any witnesses?
*
Yes
No
If yes how many witnesses:
Were there any passengers aged 15 or over in your car that were also witnesses?
Yes
No
If yes how many passengers:
How many witnesses/Passenger overall?
Select number of witnesses:
*
- Select -
None
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Witness
1
:
Title:
Mr
Mrs
Ms
Miss
First name
Middle Name
Last Name
Age
Address
Postcode
Mobile
Home Phone
Work Phone
Email:
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