Submit a claim POLICYHOLDER DETAILS Policy Number * Insured Name * First Name Last Name Phone * Country (###) ### #### Email * Vehicle Year, Make and Model * Hire Car Coverage * Market Value or Sum Insured? * Market value Sum insured Fleet Number (if commercial) DRIVER DETAILS Driver's Name * First Name Last Name Driver's Date Of Birth * MM DD YYYY Driver's Licence No. * Driver's Licence Class * Driver's Licence Expiry Date * MM DD YYYY Years Licence Held * Any traffic convictions or accidents in last 5 years? * Yes No Any criminal offences, fines or penalties in last 10 years? * Yes No Alcohol or drugs in the 12 hours prior to accident? * Yes No Breath or blood test for alcohol or drugs undertaken? * Yes No Refused to undergo breath/blood test? * Yes No ACCIDENT DETAILS Vehicle Use * Business Private Date of Accident * MM DD YYYY Time of Accident * Hour Minute Second AM PM Accident Location * Address 1 Address 2 City State/Province Zip/Postal Code Country Describe how the accident happened. * Do you have any dashcam footage available that captured the accident? * Yes No Who do you consider at fault? * Myself Third Party *If you are at fault, advise the other driver to get a quote and provide your policy number* Were there any witnesses? * Yes No Did police attend? * Yes No If yes, Police Report Number: Was your vehicle damaged? * Yes No Is the vehicle driveable? * Yes No Current Location of Vehicle * Address 1 Address 2 City State/Province Zip/Postal Code Country ADDITIONAL INFORMATION Do you have a repairer you wish to use? Yes No DAMAGE TO OTHER VEHICLE/PROPERTY If you have information regarding the Third Party, please fill out all available details below. Other Driver's Name First Name Last Name Other Driver's Email Other Driver's Phone number Country (###) ### #### Other Driver's Address Other Driver's Licence Number Other Driver's Vehicle Year, Make & Model: Other Driver's Registration Number: Other Driver's Insurance Company / Claim Number: DOCUMENTATION CHECKLIST Do you have any of the following documentation? Photos of your damaged vehicle Photos of other party/property damage Tow invoice/receipt Repair quotation Letter of demand Any other relevant documents Thank you!
