Accident details
Who is reporting the accident?
Please Select
Owner
Actual Driver
Both Policyholder & Actual Driver
Are you claiming under your own insurance policy for the repair?
Please Select
Yes - Own Damage Claim
No - Third Party Claim
No - Reporting Only
Country of Loss
Please Select
Singapore
Malaysia
Thailand
Accident Date & Time
/
Day
/
Month
Year
Date
Hour Minutes
Location of Accident
Type of Accident
Please Select
HEAD TO REAR
MAJOR TO MINOR ROAD
CHANGE LANE / CROSS LANE
OPENING OF VEHICLE DOOR
CROSS JUNCTION
U-TURN
ROUNDABOUT
CHAIN COLLISION
HEAD ON COLLISION
DAMAGED WHILE PARK / HIT&RUN / VANDALISM
COLLIDED ONTO BICYLIST
COLLIDED ONTO MOTORIST
COLLIDED ONTO PEDESTRAIN
COLLIDED ONTO PROPERTY
SIDE SWIPE
NO COLLISION
FLOOD
THEFT
Weather Condition
Please Select
Clear
Raining
Road Surface
Please Select
Dry
Wet
Brief Description of Accident Details
Please include key information related to how the accident happened.
Was any foreign vehicle involved in accident? Type in vehicle plate if Yes.
No
Yes
No. of vehicles involved in the accident (including your vehicle)
Was the accident reported to the police? If yes, please type the station name.
No
Yes
Please upload police report (if any)
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Own Vehicle Insurance Policy
Vehicle Registration No
Vehicle Category
Please Select
Private Car
Private Hire - PHV
Commercial Vehicle
Motorcycle
Vehicle Manufacturer
Vehicle Model
Transmission
Auto
Manual
Exact purpose for which vehicle was being used at time of accident
Please Select
Private Use
Private Hire
Employment
No. Of Passengers (Including Driver*)
Passenger's Name & Gender (if any)
Own vehicle policy
Handling Insurer
Allianz Insurance
Direct Asia
Ergo
Etiqa
India International Insurance
Others
Certificate of Insurance
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Please note that document heading must show -Certificate of Insurance- | Supported formats: .jpg, .jpeg, .png, .tif, .tiff | Document max size: 50MB
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Policy number
Registered Owner Name
Registered Owner ID
Email
Mobile No.
Format: 0000 0000.
Driver Information
Driver Name
Leave it blank if owner = driver
ID Type
Leave it blank if owner = driver
Date of Birth
/
Day
/
Month
Year
Date
Driving License Pass Date
/
Day
/
Month
Year
Date
Address
Postal Code
Relationship of driver to the owner of vehicle
Please Select
SELF
EMPLOYEE
HIRER
SIBILING
PARENT
CHILD
RELATIVE
PAID DRIVER
Other Vehicle or Property
Was there any other vehicle or property damaged other than your own vehicle?
Other party's vehicle number plate / Property Name
Injured persons details
Was anybody injured in the accident? - Skip this section if N.A.
Injured Name #1
Injured Vehicle No #1
Injured Name #2
Injured Vehicle No #2
Injured Name #3
Injured Vehicle No #3
Witness details
Skip this section if N.A. - Please note that witness cannot be case related
Witness Name
Witness Contact No
Accident On Scene Pictures
Please upload the on scene pictures taken
On scene pictures
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Dashcam Video Footage
Please upload the video footage - Skip if N.A.
Video Footage
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Other Documents
Rental Agreement / Letter of Authorization to drive the vehicle (if any)
File Upload
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