Motor Claim notification form

You can notify us with the details of your claim here. Simply fill out the form below and we will be in contact with you. If you require urgent assistance, please contact us directly.

Contact Details

Insured Name

Phone

Policy Number

Vehicle Details

Registration Number

Insured Vehicle Details

Drivers Details

Name of person driving the vehicle when the accident happened.

Date of Birth

Day

Month

Year

Drivers Address

Drivers Phone Number

Drivers Licence Number

Drivers Licence Expiry Date

Day

Month

Year

Did the driver consume any alcohol, or take any drugs or medication in the 12 hours prior to the accident?

Yes

Third Party Details (if applicable)

Third Party Name

Third Party Registration Number

Third Party Phone Number

Third Party Address

Third Party Driver Licence Number

Third Party Insurer and claim reference number

Accident Details

Date and time of accident

Day

Month

Year

Time

HoursMinutes

Where did the accident happen?

How did the accident happen?

Please tell us which driver you feel is at fault and why?

What were the road conditions at the time of the accident?

Where is the damage on your vehicle?*

Other Information

Was the vehicle towed?

Yes

Was the accident reported to police?

Yes

Were there any witnesses?

Do you have a preferred repairer?

Motor Claim notification form

You can notify us with the details of your claim here. Simply fill out the form below and we will be in contact with you. If you require urgent assistance, please contact us directly.

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