Page 1 of 3 TRB Forms Area Form F4069 CFD V01 Jan 2017
Written-off Vehicle Notication Individual
Transport Operations (Road Use Management) Act 1995
Note: A write off is a vehicle damaged to the extent that the cost of the repairs is greater than the value of the vehicle, or it cannot be repaired back
to a standard that would be safe for use on roads.
Vehicle details
Registered operators details
Motor vehicles (up to and including 4.5 tonne GVM) Motorcycle Trailer (over 4.5 tonne ATM) Caravan
This form must be completed for all motor vehicles, motorcycle, trailer and caravans less than 16 years old that are assessed as a
write-off and will be recorded on the written-off vehicle register. This includes:
• motor vehicles up to and including 4.5 tonne GVM
• trailers over 4.5 tonne ATM
• motorcycle
• caravans.
Vehicle type: (Please tick)
Make
Family name
Telephone number
Given name/s
Mobile number Email address
Model
Registration number
VehicleIdenticationNumber(VIN) Date of manufacture
/ /
CustomerReferenceNumber(CRN)*
*CRNcanbeyourdriverlicence
number, adult proof of age (APA) card
number or Department of Transport
andMainRoadsCRN.
Address
Postcode
Is the vehicle in your possession?
Was your vehicle involved in an accident?
A repairable write-off sticker must be attached to vehicle within 24 hours
What are the details of the incident?
Yes
Yes
No
No
Where is the vehicle located?
Incident details
Odometer reading (if able to be read)
kms
Incident date
/ /
First incident type code:
Second incident type code: (if applicable)
Damage location 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Damage severity
Damage location 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
Damage severity
Damage location 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Damage severity
Damage location 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41
Damage severity
Referoverthepagefortheinstructionstocompletetherstand/orsecondincident
type below.
continued over page...
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Declaration
Written-off Vehicle Notication Individual continued... Page 2 of 3
Damage details (up to two incident types may be recorded)
1. Incident type code: Select the ‘incident type’ that has resulted in the damage from one of the six kinds listed below and enter
thecodeletternexttotherstincidenttype.Ifasecond‘incidenttype’isinvolved,entertheincidenttypecodeletternexttothe
second incident type.
2. Damage location and severity code: Refer to the diagrams and list below 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
rstincidenttypetablelocatedbelow.Onlyusethesecondtableifasecondincidenttypehasalsocauseddamage.
Date
/ /
Full name (please print)
Signature
Page 2 of 3 TRB Forms Area Form F4069 CFD V01 Jan 2017
Privacy Statement: The department collects information on this form under the Transport Operations (Road Use Management) Act to manage the department’s vehicle
register. This information may be released by the department to parties such as written-off vehicle inspectors, Police and to or through interstate registering authorities.
Thisinformationisaccessiblebyauthoriseddepartmentalofcersandyourpersonalinformationwillnotbedisclosedtootherthirdpartieswithoutyourconsentunless
authorised or required to do so by law.
I declare that the information given on this form is true and correct. I understand that this means that the vehicle will be recorded on
the written-off vehicle register and if at any time the information is found to be false or misleading, I could be subject to a penalty.
Incident type and Damage severity codes
Incident
Description
Incident
Type
Code
Damage Severity Description
Damage
Severity
Code
Incident
Description
Incident
Type
Code
Damage Severity
Description
Damage
Severity
Code
Impact I Heavy panel A Fire F Burnt/blistered N
Light panel B Smoke and heat O
Heavy structural C Minor smoke P
Light structural D Hail H Heavy panel A
Unrepairable E Light panel B
Major mechanical damage F Malicious/ M Major stripping H
Minor mechanical damage G vandalism/ Minor stripping I
Dismantled D Unrepairable E stripped Major vandalism J
Water W Water (salt) L Minor vandalism K
Water (fresh) M
continued over page...
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signature
click to edit
Written-off Vehicle Notication Individual continued... Page 3 of 3
Page 3 of 3 TRB Forms Area Form F4069 CFD V01 Jan 2017
Has a repairable write-off sticker been given to the customer?
Application received at
Operator details
Once processed, forward completed application forms and all supporting documents to Vehicle Identity Unit (viunit@tmr.qld.gov.au)
Ofce/Agency use only
Yes No
14 Whole vehicle 21
Chassis/structural rails
(driver)
28 D pillar passenger 35 Suspension (driver front)
15 Floor pan (passenger front) 22 A pillar passenger 29 D pillar driver 36
Suspension (passenger
rear)
16 Fire wall 23 A pillar driver 30
Engine block (cracked,
fractured)
37 Suspension (driver rear)
17
Chassis/structural rails
(passenger)
24 B pillar passenger 31 Transmission case 38 Airbag front
18 Floor pan (driver rear) 25 B pillar driver 32 Differential case 39 Airbag side
19 Floor pan (driver front) 26 C pillar passenger 33 Axle housing 40 Airbag curtain
20 Floor pan (passenger rear) 27 C pillar driver 34 Suspension (passenger front) 41 Seat belt pre-tensioner
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