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Motor Claims

Insured name *

Policy number

Contact Name *

Contact phone number *

Contact Email Address *

Registration number *

Name of registered owner *

Vehicle year *

Vehicle make *

Vehicle model *

Vehicle body *

Do you owe money on this vehicle? * Yes No

Is there any prior existing damage on the vehicle ? * Yes No

What were you using the vehicle for at the time of the accident?*

Are you registered for GST purposes? * Yes No

When did the accident happen? *

What time did the accident happen? *

Where did the accident happen? *

How did the accident happen? *

Please tell us which driver you feel is at fault and why? *

What were the road conditions at the time of the accident? *

Where is the damage on your vehicle?
Motor Vehicle Accident

Please list as per the numbers on the diagram ?