New Claim Form | Indigo Vehicle Solutions

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Client Details

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Case Ref

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ClaimType

Vehicle Registration*

Company Name*

Were you the driver?*

Yes

Your Details

Your Name*

First Name Last Name

Your Contact Number*

Your Email*

Driver Details

Driver Name*

First Name Last Name

Driver Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Date of Birth

DD slash MM slash YYYY

Driver Contact Number*

Driver Email*

Driver Licence Number

Driver Licence Type

How many years held licence

Licence Expiry Date

DD slash MM slash YYYY

In the past 5 years, has the driver had any accidents/fines?

Yes

Non-drive?

Yes

Is this a windscreen claim?*

Yes

Other Party Details

At Fault Personal Details

Name

First Name Last Name

Contact Number

Licence Number

Vehicle Registration

Insurance Company

Insurance Claim Number

Accident Details

Accident Date

DD slash MM slash YYYY

Accident Time

Accident Location

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Was the vehicle stolen?

Yes

Accident Details

In the 12 hours prior was the driver under the influence of drugs or alcohol?

Yes

Were there a witness?

Yes

Witness Name

First Name Last Name

Witness Phone

Did police attend the accident?

Yes

Police event number

Police Station

Do you require a replacement vehicle?

Yes

Any other information

File

Max. file size: 8 MB.

By submitting this form I confirm that I have obtained consent from all relevant parties to disclose their information to Indigo Vehicle Solutions and I acknowledge that Indigo Vehicle Solutions is relying on this representation in accepting this application for a replacement vehicle.

AFSL Licence Number: 532517