Motor Claim Form

Motor Vehicle Claim Form (Domestic Only)

If your vehicle is damaged, stolen, or involved in an accident, we’ll work with you to get repairs or replacements sorted as soon as possible. From minor bumps and broken windows to major accidents or theft, we’ve got you covered.
Policy Holder Information
Name*

First NameLast Name
Email*
example@example.com
Date of birth*

DayMonthYear
Date

What Happened
Date of incident*

MonthDayYear
Date
Time of incident*

Hour Minutes

AM/PM Option
Address or location where the accident occurred *
Clearly describe what happened*
Which areas of the vehicle are damaged? E.g. drivers door, rear bumper etc.*
Vehicle details (Rego, make, model, year)*
Where is the vehicle now (if towed please provide tow company and where it was towed to)
If a repairer has been engaged, please supply their details.

Other Driver Details
Were there other vehicles involved in the incident?*

YesNo
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Vehicle Registration number (Number plate)*
Were witnesses involved?*

YesNo
Only enter details of witnesses who weren't passengers in your vehicle and who are not related to you.
Name*

First NameLast Name
Phone Number*
Were police involved?*

YesNo
Date reported*

DayMonthYear
Date
Police file number
Bank details for settlement
Supporting documentation

Cancelof
Signature

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