ROAD ACCIDENT CLAIM FORM

Please provide little information for us to send you a Road Accident Claim Form

Section 2: Accident Details



Section 3: Third Party Details


Section 4: Your Vehicle Details


CompleteAuthorisedNot yet authorizedNot known

Section 5: Witness Details


Section 6: Injuries


Soft tissueBone injuryWhiplashOther

Section 7: Treatment


Section 8: Police Details


YesNo

Section 9: Statement of truth


Your personal information will only be disclosed to third parties where we are obliged or permitted to do so. This includes for the purpose of claims administration as well as disclosure to third-party managed databases used to help prevent fraud, and to regulate bodies for the purposes of monitoring and/or enforcing our compliance with any regulatory rules/codes. In addition the information you have provided will be used to complete a Claim Notification Form that we will send to the other driver’s insurers to initiate your claim. By signing and returning this form you consent to these disclosures.

If you are under 18 years of age, please make sure your parent or guardian signs this form Statement of Truth

I believe that the facts stated in this claim referral form are true.