Insurely Motor Vehicle Claim Form
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  • PART A: THE INSURED

  •  -

  • PART B: THE INSURED VEHICLE

  • Is this vehicle subject to a finance arrangement of any kind?
  • Has the vehicle or engine been modified from the maker's standard specification?
  • Is there any other insurance on the vehicle?

  • PART C: DETAILS OF DRIVER OR PERSON IN CHARGE OF INSURED VEHICLE

  •  -
  • Date of Birth
     / /
  • Licence Issue Date
     / /
  • Licence Expiry Date
     / /
  • Date and Country of Issue
     / /
  • 1. Did the driver have the owners permission to drive the vehicle
  • 3. Has the driver ever been refused vehicle insurance or had a policy cancelled or not renewed?
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  • Has the driver:

  • (a) Previously been involved in a motor accident?

  • (b) Previously been convicted or a driving offence or issued with an offence or infringement notice (including speeding)

  • (c) Been disquailified from driving or had licence endorsed, cancelled or suspended?

  • PART D: DETAILS OF ACCIDENT

  • 1. When did the accident happen?

  • Date
     / /
  • Time:
  • 5. If the insured vehicle was being driven when the accident happened: a) Did the driver consume or use any alcoholic liquor, drug or intoxicating substance in the 12 hours before the accident?
  • b)  Was the driver required to provide the Police with a breath and/or blood sample?

  • PART E: DAMAGE TO THE INSURED VEHICLE

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  • 2. Did the vehicle need to be towed?

  • PART F: OTHER VEHICLE OR PROPERTY DAMAGED

    Leave section blank if not applicable
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  • PART G: LIABILITY FOR THE ACCIDENT

  • 1. Did anyone get hurt in the accident?
  • 3. Did anyone admit liability
  • 4. Did the Police attend the accident?

  • PART H: WITNESSES TO THE ACCIDENT

  • Were there any witnesses?
  • Passenger?:
  •  -
  • Passenger?:

  • PART I: DECLARATION AND SIGNATURE

  • 1. THE INSURER IS AUTHORISED TO MOVE THE VEHICLE TO A CLAIMS ASSESSING CENTRE FOR EXAMINATION AND ASSESSMENT

    2. Material Facts

    (a) All information given to the insurer in connection with this claim (whether oral or written) is true and correct; (b) No information relevant to the claim is omitted. (a) My personal information collected by insurer in connection with this claim may be: (i) disclosed to other members of the insurance industry and Insurance Claims Register Limited; (ii) disclosed to parties repairing or replacing the subject matter of the claim; (iii) disclosed to parties who have a financial interst in the subject matter of policy; (iv) used by insurer to advise me of its other services (b) My personal information held by any other parties in connection with this claim may be disclosed to the insurer.

    Please note: We gather information about you (including your claims history) to consider your claim. The terms of your insurance policy require you to supply this information, and if you do not provide it, or if you provide any flase or untrue information, we may decline your claim.

    Your claims history is passed onto, and held by, Insurance Claims Register Limited. This enables other insurers you deal with to access it, and prevents fraudulent claims.

  • SIGNED BY THE DRIVER

  • Date*
     / /

  • ON BEHALF OF ALL APPLICANTS

  • Date
     / /
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  • Should be Empty: