Motor Vehicle Accident Claim Form
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4MOTOR VEHICLE ACCIDENT CLAIM FORM
In this claim form, we are collecting information to enable us to evaluate your claim. Under the Privacy Act 1993
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we are required to inform you about certain rights and obligations relating to the information which we are
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collecting. This is in the declaration at the end of the form. We recommend that you read it before continuing.
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• The issue of this form does not constitute an admission of liability and is issued without prejudice.
• Please return this form promptly and make sure that all questions are fully answered.
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• No liability is to be admitted to a third party.
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• No repairs are to be done without our permission.
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• If you receive any communication in any way connected with the accident please forward to us immediately.
1. Insured
Insured Name
Private Telephone
Business Telephone
Mobile Telephone
Insured Address
Finance Company or
Other Interested Party
2. Vehicle
Make and Type of Body
Year of Model
Engine No.
Registration No.
Purpose used at time of accident
Insured’s Occupation
If No, Why:
Is the Warrant of Fitness Current Yes
No
If Yes, Detail
Other Insurance
Yes
No
3. Vehicle Damage
1. Details of damage
2. Is it in a fit condition to drive?
3. Amount of estimate for repairs (attach quote if possible)
4. Where and when it can be inspected
4. Third Party Damage
Names and Addresses
Property Damage
Injuries
1. Please give details of any claim made on you
2. Did you or your driver admit liability?
3. Did the other party admit responsibility?
4. Is the other vehicle insured? If so with what Company?
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Parent category: Business