Claim Form

Claim Form

Please fill out this form so we can process your claim quickly. Takes only a few minutes.
Your Name

First NameLast Name
Phone Number Email
Date Of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Declaration & Signature
I declare that the information provided in this form is true and correct to the best of my knowledge.

I authorise Direct Claims to contact any person or organisation relevant to this claim and to act on my behalf in relation to the accident.

I understand that Direct Claims may work with its associated businesses, including Direct Claims Repair Centre, Direct Claims Accident Replacement Vehicles and Direct Claims Salvage and towing, to assist in handling my claim.
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Vehicle Details