Claim Form

Owner Address

Phone

Email

License Number:

Gender
MaleFemale

Vehicle Details

Year:
Make:
Model:
Registration:
Registered for GST? YesNo

The Drivers Details:
(If the driver is the owner leave details below blank)

Name

Address

Mobile

Email

License Number:

Gender
MaleFemale

AT FAULT PARTY DETAILS (The other driver)

Name

Address

Mobile

Email

License Number:

Gender
MaleFemale

Vehicle Details
Year:
Make:
Model:
Registration:

Insurance Details of Other Driver (At Fault Party)

Insurance Company:
Claim Number:

ACCIDENT DETAILS

Date of loss/accident:
Approximate time:
Location:
Provide a brief description:

INDEPENDENT WITNESS DETAILS
Full Name:
Contact Number:
Email:

UPLOAD Photos/Documents (if available)

Drivers/Owners License:

I Agree that By completing this form I am authorising My Motor Claim to act on my behalf in relation to a motor vehicle collision. And authorise the Release of Vehicle to the care of my representing agents, My Motor Claim.

Print Name

Date:

Signature (Sign below) with Finger or Mouse

Note: Might have to press Submit button twice. Also if UPLOADING Pics it will take time.