Knightcorp

Your Details

What's your name?

So we know who to call if we need more detail

What's your email?

so we can send you a copy of this form

Vehicle Details

Make of Vehicle:

Model:

Year:

Registration No:

Incident Details

Date:

Time:

where did the incident happen?

Street

Suburb:

Road Surface:

Dry
Wet
loose
Unknown

At the time of the accident the vehicles was:

Parked
Stationary
moving

If moving, at what speed?

Number of Other Vehicles Involved:

Describe what happened:

Damage to your Vehicle

Are you claiming for damage to your vehicle?

Yes
No

If no, please proceed to "Details of other vehicle" section

If yes, please complete the following additional questions

Was the vehicle towed?

Yes
No
Unknown

Name of towing company:

Where is the vehicle now?

Damage Area Diagram

Using the diagram above, enter the areas of damage being claimed

eg. D1, F1, F2

Details of other Vehicle

Was another vehicle involved?

Yes
No

If no, please proceed to "Details of Other Parties" Section

If yes, please complete the following additional questions

Full Name:

Best Contact Number:

Name of their insurance company:

Their policy number (if obtained):

Their Registration No:

The make, model and color of their vehicle:

Details of Other Parties

(e.g. pedestrians, owners of property or owners of animals involved)

Was another party involved?

Yes
No

If no, please proceed to "Police" section

If yes, please complete the following additional information

Other Party Full Name:

Other Party Contact Details:

Police

Did you report incident to the police?

Yes
No

If no, please proceed to "Witness Details" section

If yes, please complete the following additional questions

Name of police officer:

Station:

Date of Report:

Witness Details

Was there a Witness to the Incident?

Yes
No

If no, please proceed to the "attachments & additional information" section

If yes, please complete the following additonal information

Witness full name:

Witness best contact details:

Was this witness in the insured vehicle?

Yes
No

Attachments & Additional Information

Attach a photo of the damages:

Tip: You can upload multiple documents or images by using a ZIP. folder

Please provide any additional information or notes regarding the claim:

Lodge a Motor Vehicle Claim

Your Details

Vehicle Details

Incident Details

Damage to your Vehicle

Details of other Vehicle

Details of Other Parties

Police

Witness Details

Attachments & Additional Information

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