Accident Form
IMPORTANT: IF YOU HAD AN ACCIDENT WITH ANOTHER CAR WE NEED THE LICENCE PHOTO OF THE OTHER DRIVER, THEIR NUMBER PLATE AND PHONE NUMBER. WITHOUT THIS WE CANNOT MAKE A CLAIM ON YOUR BEHALF AND YOU WILL NOT BE ELIGIBLE FOR INSURANCE COVERAGE.
Date and Time of Accident?
*
/
Day
/
Month
Year
Date
Hour Minutes
AM
PM
AM/PM Option
What was the Location of the Accident?
*
Please add Street Name, Closest Street Number or Intersection and Suburb. If it's easier, take a phone screenshot of the location on your maps and upload it later in this form.
Was there another car or person involved in the accident? (DID ANOTHER CAR/TRUCK/VAN/PERSON HIT YOU OR DID YOU HIT THEM?) YOU MUST ANSWER THIS CORRECTLY FOR INSURANCE.
*
YES
NO
What is the Registration Number of the other vehicle?
Please enter the registration number of the other vehicle
Upload a Photo of their License Back and Front
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What is their Phone Number?
Third Party Phone Number (if known)
What is their Vehicle Make, Model and Colour?
Example: Toyota Camry White
What Happened?
*
Please outline what happened in detail.
Were the police at the accident?
*
YES
NO
UNSURE
Were there any witnesses who saw the accident?
*
YES
NO
What is their name and phone number?
Weather Conditions at the time of the accident (select all that apply)
*
Sunny
Dry
Wet Road
Raining
Sun Glare
Foggy
Cloudy/Overcast
What was the speed limit on the street the accident occured?
Is the bike rideable?
*
YES
NO
Do you require towing?
YES
NO
What is the Police Report Number?
Back
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Your full name?
*
First Name
Last Name
Your email address?
*
example@example.com
Your mobile number
*
Please enter a valid phone number.
Format: 0400-000-000.
Your Bike Registration
Enter it if known
Please upload as many images you have of the accident/damages.
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Submit
Should be Empty: