New Motor Insurance Claim Form

The information provided herewith is to enable the Company and its Solicitors to advise on and to conduct any legal proceedings which may ensue

A. Insured
B. Circumstances

Was the driver in insured employment?


C. Vehicle

Is the vehicle owned by the insured?


Is the vehicle registered in insured’s name?


If vehicle is not registered in insured’s name, state the following:

If commercial, state:

Is vehicle with repairer now?


Is the vehicle under higher purchase or loan agreement?


Note: an estimate of repairs must be sent as soon as possible if the damage is covered by the policy
D. Accident

Was the accident reported to the police?


E. Other Parties Involved

Give details of all persons including passengers in your vehicles who were involved in the accident or sustained injury or change to property.

Party 1
Party 2
Party 3
F. Witness/es
i. Witness 1
i. Witness 2
i. Witness 3
G. Full Description of Accident
I. Sketch Plan

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