Section 2: Accident Details
Section 3: Third Party Details
Section 4: Your Vehicle Details
Section 5: Witness Details
Section 8: Police Details
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.