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1300 135 485
Refer
Fast Referral
Detailed Referral
Fast Referral
Details
Referrer Name & Company
*
Client
*
First
Last
Phone Number
*
Client Vehicle Registration
Client Vehicle Repair Start Date
Date Format: DD slash MM slash YYYY
Non-drive?
Yes
No
Other details / special requests
By submitting this form I confirm that I have obtained consent from all relevant parties to disclose their information to Compass Corp and I acknowledge that Compass Corp is relying on this representation in accepting this application for a replacement vehicle.
Detailed Referral
DETAILS - Please complete as much information as possible before submitting this form
Referrer Name & Company
*
Client
*
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Phone Number
*
Non-drive?
Yes
No
Client Details
Address
Client
State
ACT
NSW
QLD
SA
VIC
WA
Postcode
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Claim Number
Email
Vehicle
Make
Model
Vehicle Registration
Vehicle Repair Start Date
Date Format: DD slash MM slash YYYY
Other Party Details
Name
Prefix
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Address
Postcode
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Home Phone Number
Mobile Phone Number
Work Phone Number
License No
Claim No
Other Vehicle Details
Make
Model
Other Vehicle Registration
Accident Details
Accident Details
Was there a witness?
Yes
No
Witness Name
First
Last
Witness Phone
Did the police attend the accident?
Yes
No
Police Event Number
Police Station Address
Has the client been injured in the accident?
Yes
No
Does the client have a valid debit / credit card?
We need this for security for any infringements or accidents in the hire car
Yes
No
Does the client give us permission to contact the at fault party or at fault party insurance on their behalf to discuss their claim?
Yes
No
Other details / special requests
By submitting this form I confirm that I have obtained consent from all relevant parties to disclose their information to Compass Corp and I acknowledge that Compass Corp is relying on this representation in accepting this application for a replacement vehicle.
We understand how upsetting being involved in a motor vehicle accident can be. Contact Compass today and one of our friendly staff will help with any questions you may have.
1300 135 485
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