Motor Incident Report Form

The sooner you report incidents the lower the cost of your claim is likely to be.

Please complete and submit this form at your earliest opportunity.

*Indicates mandatory field

    Policy Holder Details

    Policy Holder*

    Contact Name*

    Contact Email*

    Policy Number*

    Contact Number*

    Broker reference*

    Driver of Policy Holders Vehicle

    Name*

    Address*

    Type of Licence Held

    Date of Birth*

    Date Licence Obtained

    Conviction Details

    Policy holder’s vehicle

    Registration Number*

    Make*

    Model*

    Damage sustained in this incident

    Number of Passengers

    Where is the vehicle now?

    Third Party Details

    Name

    Telephone Number

    Number of Passengers in vehicle

    Address

    Registration Number

    Damage to vehicle/Point of impact

    Third Party Insurance Details

    Name

    Policy Number

    Personal Injury

    Please confirm the names of all injured parties
    (and the nature and extent of all injuries sustained in this incident)

    Incident Details

    Date of Incident*

    Location of Incident*

    Time of Incident

    Circumstances of incident (please describe what actually happened)*

    Was a scene of accident information form completed?

    Is the insured driver fully to blame for the incident?

    If ’No’ then why not

    Witnesses (please provide the names, addresses and telephone numbers of all witnesses to the incident)

    Enter Details here

    Additional Comments

    Please provide any further comments on the incident that you would like to bring to our attention

    PLEASE SUBMIT THIS FORM ONLINE IMMEDIATELY IN ORDER FOR US TO MINIMISE THE COST OF YOUR CLAIM

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