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Motor Claim Form
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19
Questions
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1
Contact Details
*
This field is required.
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2
Date and Time of Incident
*
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Minutes
AM
PM
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PM
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3
What type of Accident was it?
*
This field is required.
Please Select
Single Vehicle Collision with object or Animal
Damaged noticed after the incident
Multi-vehicle collision
Vehicle Theft
Windscreen
Hail Damage
Other
Please Select
Please Select
Single Vehicle Collision with object or Animal
Damaged noticed after the incident
Multi-vehicle collision
Vehicle Theft
Windscreen
Hail Damage
Other
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4
Other
Please describe the type of accident if there was no correct option on the slide before
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5
Incident Details
*
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6
Driver Details
*
This field is required.
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7
Confirm the following is correct for the driver
*
This field is required.
The driver did not take alcohol or drugs
No breath or blood sample was taken from the driver
Unsure
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8
Was it Reported to Police?
*
This field is required.
Yes
No
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9
Police Report Number
*
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10
Has your vehicle need to be towed?
*
This field is required.
Yes
No
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11
Tow Details
*
This field is required.
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12
Where was the damage to your vehicle
*
This field is required.
Front
Rear
Passenger Side
hail
Driver's side
vehicle written off
No Damage
Other
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13
Was a third party involved in the incident?
*
This field is required.
No
Yes, and I have their details
Yes, but I don't have their details
Unsure
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14
Third Party Details
*
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15
Witness details if any
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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16
Do you have a preferred Repairer?
*
This field is required.
Yes
No
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17
Repairer
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18
Other Details
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Ok
quote
Created with Sketch.
Ok
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19
File Upload
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Max. file size
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