Motor Accident Insurance Claim Form

"*" indicates required fields

Insured Name*

Email*

Phone Number*

Policy number*

Insurance Product*

Vehicle year, make and model*

Vehicle registration number*

Driver’s details

Driver's name*

Date of birth*

Licence number*

Licence class*

Licence expiry date*

Years licence held*

Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (if YES, please provide details)*

Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years? (if YES, please provide details)*

Did you consume alcohol or take drugs during the 12 hours prior to the accident? (if YES, state how much and when)*

Did you undergo a breath test or blood test for alcohol or drugs? (if YES, what was the result)*

Did you refuse to undergo any of the above tests?*

Yes

Accident details

Vehicle use*

Business

Private

Date of accident*

Time of accident*

Location of accident*

How did the accident happen?*

Who do you consider was at fault?*

Myself

Other driver

Were there any witnesses to the accident?*

Did the police attend the accident? (if YES, please provide the police report number)*

Was your vehicle damaged?*

Yes

Was your vehicle towed away? (YES/NO). If YES, where is your vehicle now? Please provide Full address and Phone No*

Damage to other vehicle or property

Name of the other driver*

Residential address*

Phone number*

Licence number*

Vehicle year, make and model*

Registration number*

Other driver's insurance company/claim number*

Additional Information (optional)

Upload photo or document

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Accepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 15.

Name

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