UNCLASSIFIED SENSITIVE: PERSONAL

Written-off Light Vehicle Notification

Catalogue No. 45071563 Form No. 1584 (08/2020)

Vehicle details1.

Make

Vehicle type (please tick)

Model

Motor vehicle

Caravan Trailer

Motorbike

Engine number

VIN (17 characters)

Send this completed form to:

PO Box 3035 Parramatta NSW 2124Written-off Vehicle Unit

F 02 8335 9488

Transport for NSW

E WOVR@rms.nsw.gov.au

Incident details2.Date write-off decision made

Notifier’s or insurance reference number

day month year/ /

ABN / ACN (if applicable)

Page 1 of 3

Driver licence number

Telephone number

Client / customer number

Fax number

continued page 2

This information must be provided to Transport for NSW (TfNSW) within 7 days after the vehicle has been assessed as a write-off and before disposal of the vehicle.

Important information

Ensure that you have answered all the questions.Auto-dismantlers: You must notify TfNSW on this form of any vehicle you intend to dismantle or demolish within 7 days of making that decision.

Address

Postcode

Colour Vehicle shape

Variant Date built / Compliance date

Engine manufacturer

Engine capacity Number of cylinders Motive Power

Tare weight

Registration number State or Territory

Other (specify)

Notifier’s details3.

Surname

Given name(s)

Company name / business name (if applicable)

Type of notifier (please tick)Insurer

Auction house

Dealer

Auto dismantler

Assessor

Owner

Other (specify)

Are you making this notification on behalf of a business or another person / insurer / self insurer / auto dismantler / dealer?

Yes - supply name below

No

Email address

UNCLASSIFIED SENSITIVE: PERSONAL

Damage location and damage severity codesRefer to the diagrams and list on page 3 and match an appropriate ‘Damage severity code’ to each location where the vehicle is damaged. Enter the ‘damage severity codes’ against the numbered ‘damage locations’ in the Incident Table below.

Incident type4.

Page 2 of 3

Select (tick) the ‘incident type’ that has resulted in the damage from one of the seven kinds listed below

D - Dismantled

F - Fire

H - Hail

I - Impact

M - Malicious / vandalism / stripped

W - Water

R - Relevant Hail

Damage details5.

Damage location

Damage severity

1

2

3

4

5

6

7

8

9

10

12

13

14

15

16

17

18

19

11

20

21

22

23

24

25

26

27

28

29

30

32

33

34

35

36

37

38

39

31

40

41

Damage location

Damage severity

Incident Table

refer to page 3

If making this declaration on behalf of a company or business, please print your full name here.

Day Month Year

Date

/ /

Please read carefully before you sign. If you do not tell the truth you can be prosecuted.

Transport for NSW (TfNSW) is collecting your personal information in relation to this declaration and may retain and use it for driver licensing, motor vehicle, road transport and safety purposes. You are required to provide your personal information under road transport legislation and TfNSW may reject your declaration if you do not provide it. TfNSW may disclose your personal information to other driver licensing and vehicle registration agencies, to verify the information you provide, for enquiries about motor accidents, to confirm compulsory third party (bodily injury) insurance is current, to anyone proposing to acquire an interest in your vehicle and in respect of enquiries relating to stolen or abandoned vehicles. Otherwise TfNSW will not disclose your personal information without your consent unless authorised by law. TfNSW is subject to the Privacy and Personal Information Protection Act 1998. Your personal information will be held by TfNSW at 20-44 Ennis Road, Milsons Point NSW 2061. You have the right to access and correct the information if you believe that it is incorrect. You declare that the information on this form is true and complete. Section 307C of the Crimes Act 1900 makes it an offence for you to provide false or misleading information.

Signature

TfNSW Office Use Only

Data adjustedDetails entered on the Written-off Vehicle Register

WOVR updated

Recording officers name

Staff number

Signature

Day Month Year

Date

/ /

Customer declaration and privacy statement6.

Please note: Damage locations 10, 11, 12, 13 are for motorbike, caravans and trailers only.

*

*

*

*

*

Catalogue No. 45071563 Form No. 1584 (08/2020)

UNCLASSIFIED SENSITIVE: PERSONAL

Page 3 of 3

Suspension (passenger front)

Engine block (cracked, fractured)

28 D pillar passenger29 D pillar driver3031 Transmission case32 Differential case33 Axle housing3435 Suspension (driver front)36 Suspension (passenger rear)37 Suspension (driver rear)38 Airbag front39 Airbag side40 Airbag curtain41 Seat belt pre-tensioner

1 Passenger front

Motor vehicle

2 Driver front

6 Passenger side 3 Driver

side

5 Passenger rear 4 Driver

rear

7 Engine

8 Roof

9 Interior

Floor pan (passenger rear)Floor pan (driver front)Floor pan (driver rear)Chassis/structural rails (passenger)Fire wall

Floor pan (passenger front)

Whole vehicle1415

161718

2019

Chassis/structural rails (driver)2122 A pillar passenger23 A pillar driver24 B pillar passenger25 B pillar driver26 C pillar passenger27 C pillar driver

Caravan / trailer Motorbike

10 Front

11 Rear

10 Front

12 Left rear 13 Right

rear

Damage severity and damage locations codes

Damage Severity Codes

CLight panel

D Light structural

E UnrepairableF Major damageG Minor damageH Major stripping

A Heavy panelB

Heavy structural

I Minor strippingJ Major vandalismK Minor vandalismL Water (salt)

M Water (fresh)

N Burnt/blisteredO Smoke and heatP Minor smoke

Damage Location Codes

Catalogue No. 45071563 Form No. 1584 (08/2020)