Make a Claim Please leave us some Stars Commercial Motor Vehicle Claim The insured (to be completed by the insured) Name(s) of insured in full: Email: Phone: Address: Postcode: Particulars of motor vehicle involved in accident Year: Make: Model: Body Type: Colour: Registration no.: Expiry date: Particulars of trailer if involved Year: Make: Model: Body Type: Registration no.: Expiry date: RemoveAdd More Driver or person in charge of vehicle Surname: Given name(s): Address: Postcode: Mobile: Date of birth: Age: Driver's license no.: Class: State of issue: Expiry date: A photocopy of both sides if license and log book (where applicable) must be attached Front side Reverse side Log book Was any intoxicating liquor or drugs (includeing prescription drugs) consumed in the 12 ours preceding the accident or transit journey? YesNo Please provide details: Did the driver or person in control of the vehicle undergo a breathalyser / blood test / urine or oral fluid test / drug impairment assessment? YesNo Breathalyser: YesNo Blood test: YesNo Urine / oral fluid: YesNo Dug impairment assessment: YesNo Result(s) History your claim may be delayed if this section is not completed Details of owner(s) history - past 10 years Traffic and / or criminal offences: License suppension / cancellations: Refusal and / or cancellation of any motor vehicle policy by an insurer: Prior accidents or losses relative to any motor vehicle: Details of driver(s) history - past 10 years Traffic and / or criminal offences: License suppension / cancellations: Refusal and / or cancellation of any motor vehicle policy by an insurer: Prior accidents or losses relative to any motor vehicle: Detail of accident Date and time of accident / theft: Time (please circle): not show AMPM Exact location where accident / theft occurred: Describe in detail how the accident / theft occurred: Speed of your vehicle at the time of accident KM per hour Speed of other vehicle at the time of accident KM per hour Time and place the journey commenced and vehicle destination: Weather and road conditions at the time accident: In the driver's opinion, who was reponsible for the accident and why ?: Has any claim been made against you ?: YesNo Please provide details: Date and time accident / theft reported to police: Time: not show AMPM Did police attend the accident scene: YesNo Name and station of police officer who took accident particulars: Is police action pending: YesNo If yes, against whom: Name, address and phone number of any independent witness(es): Name: Address: Phone: RemoveAdd More Name, address of person(s) injured in the accident: Name: Address: Phone: RemoveAdd More Damage to insured vehicle Give brief details of loss or damage to you vehicle: Has a repair quotation been obtained ? YesNo If yes please attach Amount:$ Where can the insured vehicle be inspected ?: Was your vehicle towed at the time?: YesNo If yes by whom ?: Other person(s) involved in this incident Name, address and phone number of owner of vehicle or property: (If vehicle, please provide make, model, and registration no, including state where registered) Name: Phone: Address: Make: Model: Registration no.: State where registered: RemoveAdd More Name, address and phone number of other vehicle (if not owner): Name: Phone: Address: RemoveAdd More Please give description of other vehicle or property Please give brief details of loss or damage to other vehicle or property {{message}} {{message}}
