Motor_Accident_Claim_Form_121012.pdf

3652-0697-10-12-F9 MOTOR INSURANCE ACCIDENT CLAIM FORM 1. Contact Details Policy Number AAI: ______________________ Name of Insured Title (Mr/Mrs/Miss/Ms/Dr etc.) First names Last Name or Business Name Date of Birth / / Address (Postal) Suburb City or district Postcode Email address Phone: Business ( ) Phone: Home ( ) Mobile No. ( ) Fax No. ( ) Best Contact Person for this Claim If you would like us to deal with anyone on your behalf in regards to the lodgement and settlement of your claim please provide their details below: Title (Mr/Mrs/Miss/Ms/Dr etc.) First names Last Name Date of Birth / / Address (Postal) Suburb City or district Postcode Email address Phone: Business ( ) Phone: Home ( ) Mobile No. ( ) Fax No. ( ) 2. Incident Vehicle Details This section must be completed for all claims Date / / Time am/pm Location (e.g. road) where the incident took place Suburb / Town Vehicle Year Vehicle Make Model Registration Number Please clearly explain how the incident occurred. _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Claims Helpline Phone 0800