Motor Vehicle Claim - AJ Insurance Services

The issue of this form does not constitute an admission of liability on the part of the insurer

Please complete all sections.

Business name *

Vehicle registration number *

Driver surname *

Driver given name(s) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Email *

Phone *

Relationship to insured *

License number *

Expiry date *

Date of birth *

How long has the driver been licensed for this type of vehicle? *

Did the driver drink any alcohol or take any drugs in the 24 hours prior to the accident? *

Yes
No

Yes, Give details *

Did the driver undergo a breath test, breath analysis or blood test? *

Yes
No

Yes, Give details *

What was the reading? *

File upload

Drop your file here or click here to upload You can upload up to 3 files.

Date *

Day *

Time *

Where did the incident happen?

Number of other vehicles included *

If applicable, what type of goods were being transported at time of loss? *

What happened? (Describe in detail) *

Who was at fault *

Me
Other driver

Vehicle details

Vehicle driver surname *

Vehicle driver given name(s) *

Street Address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Country

Phone

Email

Registered Number

Year Make

Model of car

Colour

Property details

Property owner surname *

Property owner given name(s) *

Street address *

Address Line 1

City

State / Province / Region

Zip / Postal Code

Country

Phone *

Email *

Free text field - Describe what was damaged? *

Witness details

Witness surname *

Witness given name(s) *

Street address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Phone *

Email *

Did a police office attend the accident scene, or did you report the incident to the police? *

Yes
No

Give details *

Police officer's last name *

Rank *

Date of report *

Police officer's first name *

Station *

Please attach a copy of the police report

Drop your file here or click here to upload You can upload up to 3 files.

Motor Vehicle Claim Form

The issue of this form does not constitute an admission of liability on the part of the insurer

Duty of disclosure

Been convicted or charged with:

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