Insurer Information
Claim Type
*
Domestic
Commercial
Claims Handler
*
Claims Handler Contact Number
Claims Handler Email Address
*
Renter Information
Renter Name
*
Name
Surname
ID Number
Required for fine re-directions
Renter Email Address*
example@example.com
Insured Name
*
Name
Surname
Policy
*
Car Hire Policy Inception Date
*
Contact Number*
Please enter a valid phone number.
Format: (000) 000-0000.
Alternative Number
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to list an additional driver?
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No
Driver Name*
ID Number
Claim Information
Insurer
*
Claim Number
*
Claim Type
*
Standard
Third Party
Policy Type
*
Annual
Monthly
Incident Type
*
Please Select
Accident
Mechanical Breakdown
Service
Theft
Write-off
Other
Vehicle Condition
*
Drivable
Non-drivable
Date of loss
*
Days Required
*
Maximum Allowed Days
*
Authorisation Date
Rental Information
Vehicle Group
Please Select
A Entry Level, Manual Hatchback
B Manual Hatchback
C Manual Sedan
D Entry Level, Automatic Hatchback
E Automatic Sedan
Z Automatic Hatchback / Mini SUV
M Luxury Automatic Sedan / Mini SUV
G Luxury Sedan (BMW 3-series/Mercedes Benz C-Class or Similar)
I Manual 5–6-Seater
K / L Manual/Automatic SUV
TF Automatic SUV (Larger)
Q / Q1 Manual/Automatic 8-Seater
O1 Manual/Automatic 14-Seater
N1 Double Cab LDV
H 1 Ton Open LDV, Manual
J 1 Ton Closed LDV (Standard Canopy), Manual
M1 1 Ton Raised Body Single Cab LDV, Manual
P1 ½ Ton Utility LDV, Manual
PV 1 Ton Panel Van Closed, Manual
E1 Cargo Van
Collection Branch
Collection date and time
Return Branch
Return date and time
Additional Requests
Repairer Information
Repairer Name
Repairer Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Vehicle Registration Number
Vehicle Make
Vehicle model
Remarks
remarks with regards to vehicle repairs
Assessor Information
Assessor Name
Assessor Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Appointment Date
*
-
Day
-
Month
Year
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Document Uploads
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Assessor's report | Claim | Policy schedule | Quote
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Booking Consultant
Booking Consultant
*
Please Select
Suné Smith
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