Madwax Car Wash Kalgoorlie-Boulder Premier Automatic Car Wash

Madwax Car Wash Kalgoorlie-Boulder Premier Automatic Car Wash

Please complete the following form below to lodge a Madwax Incident Report with Madwax Car Wash – click here to view our Terms & Conditions.

Personal Details

First Name

Last Name

Email Address

Phone Number

Address

Suburb

Postcode

Incident Information

Date of Incident

Time of Incident

Date Incident Reported

Who was the Incident Reported To?

Was the Incident reported to an Employee?

Were visible warning signs evident prior to the incident?

If yes, give more detail on location of warning signs

Details of Incident (Describe what happened in detail)

Damage Summary

Damage caused toYour vehicleYour company vehicleMadwax's EquipmentOther

Equipment Involved

Vehicle Rego

Year/Make/Model of Vehicle

Colour of Vehicle

Name of Owner of Vehicle

Name and contact number of Insurance Company

Personal Injury Summary

Did the incident involve a personal injury?

Full Name of Person Injured

Age and Occupation of Person Injured

Sex of Person Injured

Address of Person Injured

Phone Number and Email of Injured Person

Nature of Injury?

Was treatment given at the scene of the incident?

If Yes, give details including Name, Occupation and Contact Number

Was transport provided to Hospital?

Witness(es)

Were there any witnesses to the incident?

Location of Witness?

Full Name of Witness

Address of Witness

Phone Number and Email of Witness

Where was the Second Witness?

Full Name of Second Witness

Address of Second Witness

Contact Phone Number and Email Address of Second Witness

Future Prevention

Terms & Conditions

The Privacy Act 1988 requires us to inform you that we collect your personal information in order to compile data and handle claims.

I have read, understood and agree to the Terms & Conditions of using the facilities at Madwax Car Wash.

I/We certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld.I/We understand that this claim may be refused if information is untrue, inaccurate or concealed.I/We acknowledge that I/we have read and understood the Privacy Act 1988 information referred to above and consent to the collection, storage, use and disclosure of personal information of all persons affected by this claim, with their approval. I/We acknowledge that if I/we do not agree to the collection of this personal information then my/our claim will not be processed.