COMMERCIAL MOTOR VEHICLE CLAIM FORM
YOUR DETAILS
Full Name:
*
Your address:
*
Contact Details:
Address:
Telephone:
Work:
Home:
Mobile:
Email:
PERSON DRIVING OR IN CHARGE OF VEHICLE
Full Name:
Contact Details:
Address:
Telephone:
Work:
Home:
Mobile:
Email:
Date of birth:
Occupation:
Relationship to policyholder
Is he or she the main driver of the vehicle?
Yes
No
Please give driver's license type and number and its validity
Has the driver had any previous accidents in the last five years? If yes, please provide details.
Yes
No
Has the driver ever been charged or convicted of any criminal convictions (including traffic offences, but not parking offences), or is the driver currently facing a prosecution? If yes, please list each offence or prosecution and each sentence received.
Yes
No
Has the driver had any medical condition that could affect his or her fitness as a driver (including but not limited to diabetes, epilepsy, heart conditions, physical or mental illness or disability)? If yes, please list full details.
Yes
No
Had the driver consumed alcohol, drugs or any intoxicating substance within 12 hours immediately before the accident? If yes, please list type, purpose and quantity.
Yes
No
Has the driver undergone a breath or blood test since the accident? If yes, please indicate result.
Yes
No
VEHICLE DETAILS
Vehicle registration number
*
Warrant of fitness number
Year of manufacture
Make/model
Date of purchase and purchase price
CC rating
Name and address of registered owner
Is the vehicle the subject of any hire, lease or finance arrangement?
Yes
No
Has the vehicle been modified in any way?
Yes
No
Is there any other insurance on the vehicle or accessories?
Yes
No
If you have answered yes to any of the above questions, please write full details below.
Was the vehicle being used with the policyholder's knowledge and permission?
Yes
No
If commercial vehicle, state nature and weight of goods carried
ACCIDENT DETAILS
Please describe the circumstances of the accident
*
What were the date, time and lighting conditions?
*
Where did the accident happen?
*
What were the weather conditions?
What were the road surface conditions?
What was the speed limit in the area of the accident, and what was your speed immediately before the accident?
Please draw a sketch of the accident (including lay-out of road, approximate measurements, names of streets and roads, position of vehicles and persons involved, direction of vehicles which were travelling, registration marks of all vehicle, any road markings, road signs, traffic lights, street lights and pedestrian crossings).
Did the Police attend the accident? If yes, please advise date reported/station/police file number.
Yes
No
Please list any witnesses (including passengers travelling in your vehicle) to the accident. (Include name, telephone number, address and where the witness was at the time of the accident.
If other vehicles were involved, have they made a claim against you? Please list name, address and telephone number of owner/driver, making and model of vehicle, registration number, any damage, and insurance held.
Was there any other property damaged?
Please give particulars of damage and estimated cost of repairs (if known) including any repair estimates obtained.
Was there any un-repaired damage or rust in the vehicle before the accident? If yes, please describe.
Yes
No
Whom can we contact to make an appointment to inspect the vehicle?
YOUR PRIVACY
We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993.
You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim.
We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers.
YOUR PRIVACY
I declare that:
1 All information given to New India in connection with the claim is true.
2 No information relevant to the claim has been omitted.
3 I authorize:
3.1 New India to disclose this information to:
3.1.1 Other members of the insurance industry (including Insurance Claims Register Limited), and
3.1.2 Financially interested parties noted on the policy, and
3.1.3 Parties repairing or replacing your property.
3.2 The disclosure of my personal information held by any other parties to New India for the purpose of considering and administering the claim.
;