Motor Accident Insurance Claim Form

Submit your claim

Page: Claims - Motor Accident

"*" indicates required fields

Personal information of insured

Driver's details

DD slash MM slash YYYY
DD slash MM slash YYYY
Did you refuse to undergo any of the above tests?*

Accident details

Vehicle use*
DD slash MM slash YYYY
Who do you consider was at fault?*
Was your vehicle damaged?*

Damage to other vehicle or property

Do you have a supporting quote, invoices or photo’s that will assist us to lodge your claim with your insurer? (If yes – please email these to
This field is for validation purposes and should be left unchanged.