1. I am authorised to submit this claim as:
   - the insured person,
   - a broker who has been appointed as the agent of the insured person,
   - a fleet manager or custodian of a fleet vehicle,
   - an authorised representative of the insured person or an insured company, or
   - a nominated driver on a policy;
2. I am authorised to provide this information to you for the purpose of making this claim; and
3. the information given in this form is truthful, accurate and complete, and no information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate or concealed.