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Motor Accident Claim Form
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Your Details
Name of the Insured
Phone
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Email
*
Policy Number
Drivers Details
Name
*
First
Last
Date of Birth
Address
Address Line 1
City
State / Province / Region
Postal Code
Phone
Drivers Licence Number
Drivers Licence Expiry Date
Years of driving experience:
Drivers History
Please tick the boxes for any of the below that apply:
In the last 5 years your licence has been cancelled or suspended
In the last 5 years you have had a drink driving or drug conviction
I have had limitations or restrictions on your licence
I had consumed alcohol, drugs or prescription medications 12 hours prior to the incident
If you ticked any of the above boxes, please provide details below:
The Insured Vehicle
Car Registration
Car year, make & Model
Do you owe any money on the vehicle?
Yes
No
If you owe Money on the vehicle please advise the amount owing and the name of the lender:
Has the vehicle been modified from the manufacturer's specifications? If yes, provide details:
Incident Details
What date and time did the incident occur?
Date
Time
What was the location of the incident?
Address Line 1
City
State / Province / Region
Please tell us in detail what happened:
Did the police attend?
Yes
No
Police Report Number:
Third Party Details
Name of Driver/Owner of the Vehicle
First
Last
Phone
Address
Address Line 1
City
State / Province / Region
Postal Code
Registration Number
Year, Make & Model of the third parties car:
Licence Number
Third Parties Insurance Company
Third Parties Policy Number
Witness Details
Was there any witness to the vent?
Yes
No
If yes, please provide details below
Name
First
Last
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
Where was the witness when the incident occured?
Preferred Repairer
If you have a preferred repairer, please provide their name, address & phone number below:
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Common area liability
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