Commercial Motor and Motor Fleet Claim Form

Driver's details

Driver or person last in charge of your vehicle

Name

Date

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

Driver's licence no.

Classes

Expiry date of driver's licence

Years held

Type of licence

Full
Probationary
Learners

Has the driver had any accidents, traffic convictions and/or penalities in last 5 years?

Has the driver's licence ever been suspended or cancelled?

Yes
No

When

State reason

If the driver is not insured, please state

Was the vehicle being driven with the Insured's knowledge or consent?

Yes
No

Was the driver a paid employee of the Insured?

Yes
No

Was the driver taken to the hospital?

Yes
No

Had the driver consumed any drugs or alcohol with in 24 hours preceding the accident?

Yes
No

Please state the nature and quantity of drugs and/or alcohol consumed

Was a blood, breath or urine test carried out?

Yes
No

Give details of type of test

Blood Test
Urine Test
Alco-Test
Full Breathalyser

What was the reading?

Step 1 of 9 - Insured

Insured's details

Vehicle details

Driver's details

If the driver is not insured, please state

Police, traffic and other action against you or your driver

Give Details

Section Break

Vehicle information

If goods carrying vehicle please state

Tow away details

Details of other vehicle or property

Details of all witnesses

Please provide details

Details of accident

Please give details

Declaration