Motor Vehicle Claim Notification

General Details

GST Details

Incident Details

Your Details

Driver Details

Driver Details (continued)

In the past 5 years has the driver in this incident:

Witness 2

Your Vehicle Details

If Yes Lender’s name & approximate amount owing

Other Persons

If Yes, Officer’s name and name of station

If Yes, Officer’s name, name of station & date reported

Signature & Declaration

I/we certify that the information given in this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/we understand that this claim may be refused if information is untrue, inaccurate or concealed.

Settlement By Direct Debit

Some Insurers offer settlement by Direct Debit into your Bank Account. If this option is available with your insurer and you wish to take this option please provide your bank account details below.

N.B. If you have any photos, documents or diagrams that relate to this claim, please attach to this form and submit.