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Road Accident Claim Form

Section 1: Client Details

Section 2: Accident Details

DriverPassengerPedestrianCyclistMotorcyclist
SunRainSnowFogIce
DryWetSnowIceMudOil

Section 3: Third Party Details

Section 4: Your Vehicle Details

YesNo
YesNo
CompleteAuthorisedNot yet authorizedNot known
YesNo
YesNo

Section 5: Witness Details

Section 6: Injuries

Soft tissueBone injuryWhiplashOther

Section 7: Treatment

YesNo
YesNo
YesNo

Section 8: Police Details

YesNo

Section 9: Statement of truth

Your personal information will only be disclosed to third parties where we are obliged or permitted to do so. This includes for the purpose of claims administration as well as disclosure to third-party managed databases used to help prevent fraud, and to regulate bodies for the purposes of monitoring and/or enforcing our compliance with any regulatory rules/codes. In addition the information you have provided will be used to complete a Claim Notification Form that we will send to the other driver’s insurers to initiate your claim. By signing and returning this form you consent to these disclosures.

If you are under 18 years of age, please make sure your parent or guardian signs this form

Statement of Truth

I believe that the facts stated in this claim referral form are true.