Motor Accident Insurance Claim FormSubmit your claim"*" indicates required fieldsEmailThis field is for validation purposes and should be left unchanged.Insured Name*Email* Phone*Policy number*Insurance Product*Vehicle year, make and model*Vehicle registration number*Driver's detailsDriver's name*Date of birth* DD slash MM slash YYYY Licence number*Licence class*Licence expiry date* DD slash MM slash YYYY Years licence held*Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (if YES, please provide details)*Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years? (if YES, please provide details)*Did you consume alcohol or take drugs during the 12 hours prior to the accident? (if YES, state how much and when)*Did you undergo a breath test or blood test for alcohol or drugs? (if YES, what was the result)*Did you refuse to undergo any of the above tests?* Yes NoAccident detailsVehicle use* Business PrivateDate of accident* DD slash MM slash YYYY Time of accident*Location of accident*How did the accident happen?*Who do you consider was at fault?* Myself Other driverWere there any witnesses to the accident?*Did the police attend the accident? (if YES, please provide the police report number)*Was your vehicle damaged?* Yes NoWas your vehicle towed away? (YES/NO). If YES, where is your vehicle now? Please provide Full address and Phone No*Damage to other vehicle or propertyName of the other driver*Residential address*Phone number*Licence number*Vehicle year, make and model*Registration number*Other driver's insurance company/claim number*Additional Information (optional)Upload photo or document Drop files here or Select filesAccepted file types: jpg, jpeg, png, pdf, doc, docx, xls, xlsx, Max. file size: 5 MB, Max. files: 15. GET A QUOTEDiscover the Elliott Insurance difference request a quote