Motor Insurance Claim Form

Your Name:*

First Last

Your Phone:*

Your Email:*

Is this Vehicle insured under a Business Name?*

Yes

Please Enter Your Business Name:*

Who shall we contact with claim updates?*

Someone else

Please enter the email for our point of contact for this claim*

Were you driving at the time?

Name of the driver at the time*

First Last

Driver Date of Birth*

How many years has the Driver held a full driving licence for? (Excluding L Plates)*

Has the Driver had any traffic offences or licence suspensions in the last 5 years?

If Yes please provide details

What time did it happen?

When did the accident happen?*

What Happened?

A brief description of what occurred (20 words or less). If you want to provide a longer description of what occurred please enter it below.

Longer Description of What Occurred (Optional)

If you want to provide a more detailed description of what occurred please enter it in this box.

Your Vehicle Registration No.*

Where did the accident happen?*

Street Address City

Your Vehicle Year, Make and Model

Where is your vehicle?

Repairer's Address*

Repair Name Street City State / Province / Region

Phone*

Do you have a Preferred Repairer you want to use?*

Yes

Preferred Repairer's Address*

Repair Name Street City State / Province / Region

Phone*

Did the Police attend?

Were you breathalysed or drug tested?

Was there a Third Party involved in the accident?

Who do you think was at fault?

Third Party details

First Last

Address of Third Party

Street Address City State / Province / Region

Third Party's Phone Number

Third Party Registration No.

Was there a witness?

Witness Details

Name Address City State / Province / Region ZIP / Postal Code

Witness' Phone Number

Please upload photos of drivers licence, photos of damage and Third Party licence ( if applicable)

Drop files here or

Accepted file types: pdf, docx, Max. file size: 128 MB, Max. files: 5..

Your Signature:*

Accepted file types: jpg, gif, png, Max. file size: 128 MB.

Date and Time Completed*

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