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Motor Vehicle Accident Claim
Policy Owner Details
Policyholder Type
*
Please Select
Private
Corporate
Email Address
*
Phone No
*
Address
*
City
*
State
*
Tick box if driver was a policyholder at the time of accident
*
Driver Details
Name
*
Address
*
Pictures of Damaged Vehicle
All Attachments Must be In PDF or JPEG Format
Upload Picture 1
*
Upload Picture 2
*
Upload Picture 3
*
Estimate Of Repairs
*
Vehicle Details
Policy Number
*
Vehicle Registration Number
*
Details of Incident
Date of Incident (yyyy-mm-dd)
*
Time of Incident
*
Details of Incident
*
Where was the car damaged?
*
Driver side
Front wing
Front door
Rear door
Rear wing
Passenger side
Front wing
Front door
Rear door
Rear wing
Car centre
Front
Bonnet
Front window/screen
Roof
Rear window/screen
Boot
Rear
Witness 1 Name and Contact Details (Tel/Email etc)
*
Witness 2 Name and Contact Details (Tel/Email etc)
Statement of Authenticity/Truth of Details Given Above (Please Tick Box).
*
Submit
