Motor Claim Form Name of Insured (required) Mobile Number Your Email (required) Physical Address (required) Postal Address (required) Details Driver Involved in accident He/She is the ? ---OwnerEmployeeRelativeFriend Did the owner authorise the journey ---NoYes Purpose vehicle was being used for When was driver licensed to drive?: ---NoYes Name of vehicle Make Reg Number Address where loss occured Time of loss Loss Date (required) Describe fully how the loss occured Weather conditions Road Surface Full Extent of damage Estimate Repair cost: Details of injuries or passengers if any: Name of passenger(s) injured: Damage to third party property or bodily injury: Name(s) of third parties: Police Report: Drivers license copy Attach 3 Quotations from reputable garage below Attach 3 images to show damage By submitting this form you accept the Terms & Conditions [recaptcha size:compact]
