Online Claims - Freisenbruch

Basic Details

Policy holder*

Address*

Phone number*

Email address

What kind of claim are you making?*

Broking Claims

This form is intended for general, home, marine and motor claims. For broking claims, please contact your designated representative via email or through our contact page.

General Claims Details

Incident date*

Reported to authorities? (if applicable)

Yes
No

Investigating officer / Station

Case number

Summary*

Please provide a summary of the cause, nature and extent of the accident / loss / damage:

Motor Claims Details

Insured Vehicle

Vehicle registration number*

Make and model*

What was the vehicle was being used for?*

Driver Details

Was the policy holder also the driver?*

Yes
No

Was the vehicle used with the permission of its owner?*

Yes, the vehicle was used with permission

Driver's name*

Driver's address*

Driver's phone number*

Driver's email address

Driver's date of birth*

Driving License number*

Driving License expiry date*

Date driver passed test*

Permitted vehicle classes*

Has the driver been convicted of any motoring offences during last 5 years, or are any charges being brought as a result of this accident?*

Yes
No

Has the driver been involved in any accident in last 5 years?*

Yes
No

Please provide brief details:*

Details of Accident

Date of Accident*

Time*

Place*

Describe the accident in your own words*

Damage to policy holder's vehicle*

Did police attend?*

(Please attach report if available)

Yes
No

Name, relationship, and address/phone number of any passengers

Witnesses, if any

Third Party ("TP") details

TP property owner

TP Phone Number

Details of TP property

Nature/extent of damage

Details of TP injuries, if applicable

Attachments

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Agreement

I/We hereby declare that, to the best of my/our knowledge and belief, the foregoing statements and those on supplementary documents, are fully and truly made. I/We acknowledge and understand that any misrepresentation, fraudulent act, or statement made in support of my/our claim will lead to the claim being voided, and may result in criminal prosecution. I/We confirm that/there is no other insurance policy in effect which would indemnify me/us for this Loss. I/We agree that insurers may, at their option, make settlement of any claim, suit, or Action for Damages that may be made against me/us in respect of the above incident.

I/We declare that there is no other insurance in effect, which would cover this accident, and I warrant that to the best of my knowledge these statements are true. I understand that making a false statement in support of my claim will invalidate my claim under the policy, and may render me liable for criminal prosecution.

I/We agree that insurers may, at their option, undertake the settlement of any claim, suit, or action for damages that may be made against me/us in respect of the reported accident.

Acceptance of terms*

I / We agree to the terms listed above

Today's date

Signature

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Name

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Freisenbruch - Online Claims

Make a Claim Online