Claims Form

    *Please Select

    *Email Address

    *Telephone Number

    *Address

    *City

    *State

    *Was driver a Policy Holder at the time of accident? YesNo

    Driver details:
    *Full Names

    *Address

    Pictures of damaged vehicle:
    - All attachments MUST be in PDF or JPEG formats -

    *Upload picture 1

    *Upload picture 2

    *Upload picture 3

    *Upload picture 4

    Vehicle details:
    *Policy Number

    *Vehicle Registration Number

    Details of Incident:
    *Date of Incident

    *Time of Incident

    *Details of Incident

    Where was the car damaged?

    *Driver Side: Front WingFront DoorRear DoorRear Wing

    *Passenger Side: Front WingFront DoorRear DoorRear Wing

    *Car Centre: FrontBonnetFront Window ScreenRoofRear Window ScreenBootRear

    *1st Witness - Full Details

    *2nd Witness - Full Details

    *These statements provided above are authentic & truthful? Yes

    claims form
    Accident Image