Claim Application

Your Details

Owner of vehicle (on registration)

Phone

Owner Address

Vehicle Details

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Registration

Licence Details

Licence Number

Licence State

Licence Expiry

Licence Photo

At-Fault Driver Details

Full Name

Address

Phone

Date Of Birth

Licence Number

Vehicle Year

Vehicle Make

Vehicle Model

Vehicle Registration

Accident Details

Date of Accident

Accident Location

Accident Description

Insurance Details of Other Driver

Insurance Company

Claim Number

Is Your Car Driveable?

Yes No

I confirm that the details in this form are accurate and correct

Yes

I have read, understand and accept the Terms and Conditions on this page.

Yes

I authorise Car Rentals Near Me to act on my behalf in recovering the replacement vehicle costs, communicating with the insurer in regards to the claim and commencing legal proceedings if the matter is in the situation where it must be defended in a court of law

Yes

Accepted & Digitally Signed By: