Motor Vehicle Claims

Claim Form - Motor Vehicle

DD slash MM slash YYYY
Address where incident occurred(Required)
Please provide images of the damage
Accessories and/or Modifications
Name of Driver(Required)
DD slash MM slash YYYY
Has the driver's licence ever been cancelled?
Has the driver been involved in previous accidents in the past three years?
If Yes, please provide details within the Additional Information section
Was any intoxicating liquor and/or drugs (prescribed or otherwise) consumed by the driver in the 12 hours prior to the accident?
Was a breathalyser, blood test or any other test requested?
Was the incident reported to the police?
Third Party's Details - Name
Witness Details - Name
DD slash MM slash YYYY
Drop files here or
Accepted file types: png, jpg, pdf, doc, docx, Max. file size: 16 MB.