DECLARATION & AUTHORITY

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Last Name

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Declaration & Authority to Act

I confirm that, to the best of my knowledge, the information I have provided is accurate, complete and not misleading; *

I acknowledge that I have read, understood and agree to IMOK's Privacy Policy; *

I acknowledge that I have read, understood and agree to IMOK's Terms and Conditions; and *

I confirm that I authorise IMOK Accident Replacement Cars (ABN 11 619 986 511 - PO Box 109 Oatlands NSW 2117) to act on my behalf in respect of the recovery of the hire costs and the management of my vehicle repairs. *

Your Signature

Date required

Upload Required Documents

Your Driver's Licence

UPLOAD

Front Side

Your Driver's Licence

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Back Side

Your Vehicle Registration

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Copy of Most Recent Registration