WidgetGuard Insurance Brokers

Claim Notification - Motor Insurance Claim Form

Please provide your details below.

Please fill in the details below as accurately as possible to help us progress with your claim.
Personal Information
Insured Name
Address
Email
Phone
Policy Number
Vehicle year, make and model
Registration number
Driver's details
Driver's name
Date of birth
Licence number
Licence Class
Licence expiry date
Have you had any traffic convictions or been involved in any motor vehicle accidents in the past five (5) years?
Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years?
Please list description, sum claimed and purchase date of each item
Insurance history
Have you had any claims in the last 5 years? (YES / NO If Yes, provide details.)
Has any Insurance Company refused to renew or cancelled/terminated a policy? Has any Insurance Company refused a claim? (YES / NO If Yes, provide details.)
Have you been convicted of or had any fines or penalties imposed for any criminal offences in the last 10 years? (YES / NO If Yes, provide details.)
Additional Information (optional)
Supporting document	Browse...
Did you consume alcohol or take drugs during the 12 hours prior to the accident?
Did you undergo a breath test or blood test for alcohol or drugs?
Did you refuse to undergo any of the above tests?	Yes No
Accident details
Vehicle use
Date of accident
Location of accident
How did the accident happen?
Who do you consider was at fault?
Were there any witnesses to the accident?
Did the police attend the accident? (if YES, please provide the police report number)
Was your vehicle damaged?	Yes No
Was your vehicle towed away? (YES/NO). If YES, where is your vehicle now? Please provide Full address and Phone No
Damage to other vehicle or property
Name of the other driver
Residential address
Licence number
Registration number

WidgetGuard Insurance Brokers, where tradition meets innovation.

Whether you seek coverage for your zeppelin fleet, enchanted artifacts, or mundane minivans, our brokers - armed with laptops and espresso machines - stand ready.
We're not just about policies; we're about peace of mind.

So, dear client, step into our oak-paneled office, sip your tea, and let us weave a protective cocoon around your dreams.
Because at WidgetGuard, we don't just insure widgets; we guard legacies.