Motor Vehicle Claim (Non Theft) - Aughtersons Insurance

Non theft motor vehicle claim form.

Vehicle Details
Make of Vehicle*
Model*
Year*
Colour*
Registered No.*
Odometer Reading*
Registered Owner*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Do you owe money on your vehicle?*
- Yes
- No
Name of Lender
Account Number
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Driver Details
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contact Business
Private
Fax
Mobile
Relationship to Insured*
Date of Birth*
Licence Number*
Expiry*
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
If yes, give details
Did the driver undergo a breath test, breath analysis or blood test?*
- Yes
- No
If yes, what was the reading?
Please attach a copy of the certificate?
Max. file size: 64 MB.

Damage To Your Vehicle
Are you claiming for the damage to your vehicle?
- Yes
- No
Was the vehicle towed?
- Yes
- No
Name of towing company
Where was it towed?
Distance towed (kms)
Where is the vehicle now?
Describe the damage to your vehicle, including point of impact.
For example. Front bumper dented, right side passenger door dented and scratched, front right headlight broken etc.

Owner of Other Vehicle
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone Business
Phone Private
Insurance Company
Policy No.

Driver of Other Vehicle
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Date of Birth
Driver's Licence Number
Was the owner in the vehicle at the time of the accident?
- Yes
- No

Other Vehicle
Registration No.
Year of Manufacture
Make of Vehicle
Model
Colour
Describe the damage to the other vehicle, including point of impact.
For example. Front bumper dented, right side passenger door dented and scratched, front right headlight broken etc.

Other Parties
Give details of pedestrians, owners of property of owners of animals involved.
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Police
Did the police attend the accident scene?
- Yes
- No
Or did you report the incident to the police?
- Yes, give details below
- No
Name
First Last
Rank
Station
Date of Report
MM slash DD slash YYYY
Attach copy of the report
Accepted file types: pdf, jpg, png, Max. file size: 4 MB.
Name of person to be charged or cautioned
First Last
Nature of charge or caution

Witness(es) Details
Witness 1
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Was this witness in the insured vehicle?
- Yes
- No
Witness 2
Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Private)
Was this witness in the insured vehicle?
- Yes
- No

Quotation
Please attach ONE quotation from repairer here.
Accepted file types: pdf, jpg, png, Max. file size: 4 MB.

Declaration and Authorisation
The information and answers given above are true and complete in every detail.
I understand the claim may be refused or reduced if information if withheld.
The Insured
Name of Insured
First Last
Signature
Date
MM slash DD slash YYYY
The Driver
Name of Driver
First Last
Signature
Date
MM slash DD slash YYYY
Please check that this claim form has been fully completed as any omissions may delay your claim.*
Click below to enable your claim to be submitted.
- Yes
- No
Comments
This field is for validation purposes and should be left unchanged.

Name of Driver	Date of Incident	Details of Incident	Insurer	Person at Fault

Motor Vehicle Claim Form (Non theft)