This document is a taxi insurance claim form that contains important information about filing a claim. It requests details about the insured taxi operator and driver, describes what to do if an accident occurs, requests a description of any vehicles or property damaged, and asks questions about injuries, witnesses, fault and more. Signing the form allows the insurance company to obtain relevant information and assess the claim in a timely manner.

1. Taxi Insurance
Claim form
IMPORTANT NOTICE – OMISSION OF RELEVANT INFORMATION MAY DELAY ATTENTION TO YOUR CLAIM
Important information
• Do not admit liability – Ask for any claim to be put in writing and refer all correspondence to ZURICH AUSTRALIAN INSURANCE LIMITED.
• Make sure you give us all the details about your claim. Attach a separate sheet if you have insufficient space on this form.
• Send all quotations you have received to repair your vehicle and/or any quotations or correspondence you may have received from any other
party in relation to this accident.
General Insurance Code or Practice
Zurich Australian Insurance Ltd is a signatory to the General Insurance Code of Practice. For more information about the General Insurance
Code of Practice please go to www.zurich.com.au and select About Zurich.
Brokers please note: You can monitor the progress of a claim via Zurich Claims Online 24 Hours a Day, 7 days a week.
Privacy
• We need personal information about you to assess your claim. We will, where relevant, disclose your personal information (other than
sensitive information such as health information) to your adviser (and any licensee or broker he or she represents), to our service providers
(including loss adjusters and investigators), other insurers, insurance reference bureaus and our business partners for this purpose;
• Where relevant, to assess your claim we will also disclose personal information, including sensitive information about you such as health
information, to medical practitioners, other health professionals, other insurers and reinsurers, legal representatives, and other consultants.
By signing this Claim Form, you consent to those organisations and other professionals collecting, and us disclosing sensitive information
about you for this purpose;
• In some cases, assessment and settlement of the claim is undertaken in conjunction with our insured. For example, we may act as an
agent for our insured or the cost of claims may be shared between us and our Insured. In these cases, your personal and/or sensitive
information will be shared between us and our insured (or their representatives) for the purpose of managing the claim;
• A list of the type of service providers, business partners and consultants we commonly use is available on request, or on our website - go
to www.zurich.com.au and click on the Privacy link on our home page;
• If you do not provide the requested information or consent to its collection and disclosure as described above, the assessment of your
claim may be delayed or we may not accept the claim;
• We may also disclose personal information about you where we are required or permitted to do so by law;
• In most cases, on request, we will give you access to the personal information we hold about you;
• If you would like to find out more, you can contact us by telephone on 132 687, e-mail us at Privacy.Officer@zurich.com.au or write to
'The Privacy Officer' at Zurich Financial Services Australia Limited, PO Box 677, North Sydney, 2059. Please provide details of your policy
number/s and/or claim number where known.
1 The insured – Taxi operator
Surname Given name(s) Operator Accreditation No.
ABN ITC% %
Address State Postcode
Phone number – Private Business
Mobile Fax
2 The accident
ZU07542 - V3 06/12 - JMOY-6PV7RB-2006
Date / / Time am pm
Location – Street
Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. Taxi Insurance Claim Form – Page 1 of 4

2. 3 The insured Taxi
Year Make of vehicle Model
Registration No. Body type Chassis/Engine No.
Is the Taxi at a repairer’s premises? Yes No If ‘Yes’, state name of repairer
What parts of the Vehicle have been damaged? Shade in diagram below.
Was any part of the Taxi in a damaged condition prior to the accident?
Yes No If ‘Yes’, give details
1 2
7 Engine
6 3
8 Roof
5 4
9 Interior
4 Towing
Was you vehicle towed? Yes No If ‘Yes’, by whom?
5 The Taxi driver – Full details must be given
Surname Given name(s) Operator Accreditation No.
Address State Postcode
Phone number – Private Business
Mobile Fax
Date of birth / / Driving experience
Licence No. Expiry date / /
Was intoxicating liquor or any drug consumed by the driver within 12 hours prior to the accident? Yes No
If ‘Yes’, how much?
Did the driver undergo a breath test, breath analysis or blood test? Yes No If ‘Yes’, state reading
Have you had any traffic convictions and/or offences or been involved in any motor vehicle accidents in the past five (5) years? Yes No
If ‘Yes’, give details
Taxi Insurance Claim Form – Page 2 of 4

3. 6 Other vehicle(s) and/or property involved
Year Make of vehicle Model
Colour Registration No. Insurance company
Policy No. Insurance type
What parts of the Vehicle have been damaged? Shade in diagram below.
Owners full name
Phone
1 2 Address
State Postcode
7 Engine
Drivers full name
Phone
6 3 Address
State Postcode
8 Roof
Drivers licence number
Expiry date / /
5 4
Date of birth / /
NOTE: If more than one third party vehicle is involved, please
9 Interior complete details on an additional sheet.
Owners full name
Address State Postcode
Description of property damage
7 Reporting to the Police
Police Station to which the accident was reported
Constable’s name Whom do Police consider responsible?
If known, is any police action pending? Yes No
Against whom? Nature of charge
Did Police attend the scene of the accident? Yes No Was a P5 FORM issued? Yes No
8 Witnesses
In your Taxi
1. Name Contact telephone number
Address State Postcode
2. Name Contact telephone number
Address State Postcode
Independent witnesses
1. Name Contact telephone number
Address State Postcode
2. Name Contact telephone number
Address State Postcode
Number of persons in your Taxi vehicle? In other vehicle?
Taxi Insurance Claim Form – Page 3 of 4

4. 9 Injuries
Was any person injured? Yes No If 'Yes', give details
10 Responsibility for the accident
Who do you consider to be at fault? Why
11 Description of accident
Please state fully how accident occurred (use separate sheet if necessary)
Please draw a PLAN OF ROADWAY where accident happened.
1. Indicate lane markings - - - - - 2. Show give way and stop signs S 3. Show traffic control lights 4. Indicate direction with
5. Show your vehicle I other vehicles A B
12 Declaration
I declare that the above particulars are true in every respect, and no The above mentioned is, to the best of my knowledge and belief, true
information is being withheld or misrepresented. in every respect, and no information is being withheld or misrepresented.
I agree that Zurich Australian Insurance Limited (the “Company”) I agree that Zurich Australian Insurance Limited (the “Company”)
may release the information set out in this Claim Form (including may release the information set out in this Claim Form (including
without limitation, my age, Licence number and driver authority without limitation, my age, Licence number and driver authority
number) to the Insured’s Taxi Group/Company and to the NSW Taxi number) to the Insured’s Taxi Group/Company and to the NSW Taxi
Industry Association. Industry Association.
Signature of driver Date Signature of insured operator Date
✗ / / ✗ / /
Taxi Insurance Claim Form – Page 4 of 4