E-Claim Form

E-Claim Information

Please have the following details ready to complete your online claim.

We have already pre-filled the form with information you have provided us by phone. However, there are some specific items needed for your claim.

Given name
Surname
Primary Phone Number
Alternate Phone Number
Email Address
Date of Birth
Gender
Licence Number
Licence Expiry
Licence Country
Licence State
Have you had any accidents, traffic convictions and/or penalties in the last 5 years?
Have you consumed any alcohol or taken drugs within 24 hours prior to the incident?
Your Correspondence Address (your full mailing, residential or business address)

Incident location (closest street address)
Weather at the time of the incident
Lighting condition at the time of the incident
Whether visibility in general was any good
Approximate speed of vehicle just before the incident
Colour of traffic light facing your vehicle, if any
The type of sign facing your vehicle, if any
State and condition of the road surface
Position of your vehicle (i.e. moving forward, reversing, stationary, parked etc).
Description of the incident
Whether another vehicle was involved
Has there been loss or damage?

Were there any independent witnesses (i.e. not in your vehicle) over 18 years old?
Were there any passenger witnesses (i.e. in your vehicle) over 18 years old?
Name address and phone number of witnesses

How many other vehicles participated in the incident?
Whether any other party admitted liability
Name, address, phone number and licence details of any other parties (and/or other partys' registered vehicle owners' details)
Other vehicles' registration, make & model, body type, primary colour and insurance details (insurance company name, policy number, claim number)