Accident Claim Form
Personal Details
Name:*
Address:
Phone:
Email:
Driver Date of Birth:
Driver's licence number:
Driver's licence class of license:
Driver's licence country of issue:
Select the country
Driver's licence expiry date:
Driver's driving experience (in years):
Did the driver consume any alcohol/drugs within 12 hours prior to the collision?
Yes
No
Please advise the type and quantity:
Did the driver undergo a breath or blood test following the accident?
Yes
No
Please state the result of the breath or blood test:
Has the driver's licence been suspended or cancelled in the last 5 years?
Yes
No
Please explain when and why:
Use of vehicle at the time of the incident:
Private
Work / Business
Who do you consider at fault?
3rd Party / Other Driver
Myself
Registration Number (REGO):*
Please mark the areas of damage on the car:
Clear Marks
Upload Photos and Files
Accepted formats: JPG, PNG, PDF. You can upload multiple files.
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Third Party Information
Add a Third Party
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Accident Details
Date of Incident:*
Location of the Incident:
What were the conditions at the time of the accident? (weather, lightning, condition of the road):
Your approximate speed at the time of incident (in km/h):
Their approximate speed at the time of incident (in km/h):
Please provide a detailed description of how the accident occurred:
Was your vehicle towed from the accident scene?
Yes
No
Towing company name:
Towing company phone number:
Please advise the location of the vehicle (full address, GPS coordinates etc.):
Is the vehicle currently at a repair shop?
Yes
No
Please provide the name of the repairer:
Repairer phone number:
Repairer email:
Repairer full address:
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Additional Details
Has your vehicle been stolen or suffered from malicious damage? (e.g. theft, burglary, malicious damage etc.)?
Yes
No
Please provide the location of where the theft occurred:
Witness Name:
Witness Phone number:
Witness Email:
Witness Address:
Police - did the police attend the scene of the accident?
Yes, police did attend the accident
No, the police did not attend the accident
Name of the Lead Officer:
Name of police station:
The report number:
The phone number of the police station:
Was the incident reported to the police?
Yes, the police were notified
No, the police were not notified
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