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Make a Claim

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    The insured (to be completed by the insured)





    Particulars of motor vehicle involved in accident







    Particulars of trailer if involved






    Driver or person in charge of vehicle












    A photocopy of both sides if license and log book (where applicable) must be attached




    Was any intoxicating liquor or drugs (includeing prescription drugs) consumed in the 12 ours
    preceding the accident or transit journey?

    YesNo

    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
    YesNo
    History your claim may be delayed if this section is not completed
    Details of owner(s) history - past 10 years




    Details of driver(s) history - past 10 years




    Detail of accident


    not show

    AMPM



    KM per hour
    KM per hour




    YesNo


    not show

    AMPM


    YesNo


    YesNo
    Name, address and phone number of any independent witness(es):



    Name, address of person(s) injured in the accident:



    Damage to insured vehicle

    Has a repair quotation been obtained ?
    YesNo


    Was your vehicle towed at the time?:
    YesNo
    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, address and phone number of other vehicle (if not owner):





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