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Road Accident Claim Form

Section 1: Client Details

Section 2: Accident Details

 Driver Passenger Pedestrian Cyclist Motorcyclist
 Sun Rain Snow Fog Ice
 Dry Wet Snow Ice Mud Oil

Section 3: Third Party Details

Section 4: Your Vehicle Details

 Yes No
 Yes No
 Complete Authorised Not yet authorized Not known
 Yes No
 Yes No

Section 5: Witness Details

Section 6: Injuries

 Soft tissue Bone injury Whiplash Other

Section 7: Treatment

 Yes No
 Yes No
 Yes No

Section 8: Police Details

 Yes No

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.