Fill - Free fillable Queensland F4069 CFD Written-off Vehicle Notification Individual PDF form

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 operator’s 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

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.

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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

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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)

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

Fill Online, Printable, Fillable, Blank Queensland F4069 CFD Written-off Vehicle Notification Individual Form

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Fillable Queensland F4069 CFD Written-off Vehicle Notification Individual

Fill Online, Printable, Fillable, Blank Queensland F4069 CFD Written-off Vehicle Notification Individual Form

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