Claim Form | Cityhop

Motor Vehicle Claim

Insured Name

Physical Address

Postal Address

Home Phone

Business Phone

Mobile Phone

E-Mail Address

Make

Model

Rego

Date of Accident or Loss

Time of Accident or Loss

Vehicle Drivable

Yes

Place of Accident

Reason for Journey

Detailed Description of Damage - include area/s, type and severity

Driver Name

Driver Date of Birth

Driver Age

Driver Email Address

Driver Phone No.

Driver Relationship to Insured

Is this Driver a Regular Driver of the Insured Vehicle?

Did the Police Attend?

Officer Name

Officer Badge No.

Police Station

Police Event No

Did the Driver consume Liquor and/or Drugs (including Medication) within 24 Hours prior to the Accident?

Was a Breathalyser or Blood Test or any such Test done?

Was there a third party involved in the accident?

Yes

Details of Main Other Vehicle Involved

Vehicle Make and Model

Rego

Driver Name

Driver Address

Phone

Include details of any other damages that need to be reported

Please write a detailed description of how the Accident or Loss happened.

Include contact details of any witness of the incident.

Please upload a sketch plan and photos of the accident

Upload requirements

Download sketch plan template

I/we declare that to the best of my/our knowledge and belief these particulars are complete and correct. I /we agree to provide or authorise the obtaining of any further information that may be required.

Driver's Signature

Date