Motor Vehicle Online Claim Form

Title

First Name *

Last Name *

Email Address *

Enter Word Verification in box below *

Home Address

Is the Vehicle Leased?

Type of Lease

Insured Vehicle Year, Manufacturer (Make) and Model *

Registration Number *

Engine, VIN or Chassis Number

Type of Vehicle *

Please list any Non Standard Accessories or Modifcations to the Insured Vehicle *

State the Time and Place the journey commenced and the intended destination *

For Goods Carrying Vehicles, please state the type of goods being carried

Drivers Full Name *

Drivers Home Address

Drivers Mobile or Home Phone Number (No Spaces or Hyphens) *

Drivers Date of Birth *

Drivers Gender *
Male
Female

Current Drivers License Number *

Expiry Date of Drivers License *

What is the relationship of the Driver to the Registered Owner *
Registered Owner
Employee
Spouse or Family Member
Friend
Other

If the driver has had any prior motor vehicle accidents, claims or driving convictions please list them here *

Were any drugs (prescribed or non-prescribed) or alcohol consumed within 12 hours prior to the accident? If so please state what was consumed and how much *

Was your vehicle Damaged? *

If yes, please describe the damage as best you can *

If your vehicle was towed away, please list where it was towed to

Please list the name, address and Phone Number of your preferred repairer

When did the accident occur (date and time) *

How was the vehicle being used at the time of loss? *
Business Use
Private Use

Please describe the environment at the time of the accident (wet, dry, light, dark, smotth, rough, uphill, downhill, flat, dirt road) *

Location of Accident (Include street number or nearest cross road if possible) *

In your own words, describe how the accident occured *

Who do you consider to be at fault (Myself, Other Driver) *

Estimated Speed of your Vehicle prior to the accident *

Estimated speed of the other vehicle(s) just prior to the accident *

Please describe any vehicle lights or signals in use by your prior to the accident *

Please describe any vehicle lights or signals in use by the other vehicle prior to the accident *

Were there any witnesses to the accident (please include their full name, phone number, and address) *

Did the police attend the accident *

Please list the Police Station, Name of the Officer, Police Report Number, and whether the police charged any of the drivers at the scene *

Please list the name, address and Phone Number of the owner or driver of the other vehicle (1) *

Please list the Year, Make, Model and Colour of the other vehicle and describe any damage you could see on the other vehicle *

Please list the name, address and Phone Number of the owner or driver of the other vehicle (2)

Please list the Year, Make, Model and Colour of the other vehicle and describe any damage you could see on the other vehicle (2)

Was anyone Inujured in the accident? If yes, list their full name, type of injury, whether they were a driver, a passenger or a pedestrian, and the vehicle registration number if they were inside a vehicle.

I confirm that the information provided is true in every detail and that no information has been withheld *

Please list any other information you beleive may be relevant

I acknowledge that this submission is not an acceptance of my claim and does not constitute any authorisation to repair my vehicle *

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