Fast Action Claim Form

NEW CLAIM - Tell us about your accident claim
- Someone hit my vehicle & I believe it was their fault
- Someone hit my vehicle & I am unsure who's fault it was
- I have damaged my vehicle & it was my fault
How are you Insured?
- Fully Comprehensive
- Third Party Fire & Theft
Who recommended Us?
Recommended Name
1. Tell us about yourself
Name
Telephone
Email
Full Address
Crash Guard Member
Are you a crash guard member?
Crash Guard is our membership that gives you the driver many benefits to include: *Excess Protection * Replacement Vehicles *Legal Cover * Roadside Recover
- I am a Crash Guard Member
Membership Number

4. Your Insurance Details
Insurance Company Name
Policy / Claim No.
Policy Expiry Date
5. Third Party Details
Name
Telephone
Third Party Full Address
Make
Model
Registration Number
Third Party Insurance Company Name
Third Party Policy No
I would like to claim for the following:
I would like to cliam
- Repairs to my vehicle
- I need a replacement vehicle
- I need help with my injury claim
Agree to Privacy Policy*
I am happy with how you handle the information entered above, as explained in your privacy policy
- I agree to the Privacy Policy

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