Accident Claim Form
Before we can bring a claim for accident compensation on your behalf, we require you to complete our Accident Claim Form below.
Upon receipt of your completed Accident Claim Form one of our team will contact you to discuss your potential claim for compensation. Please note that all questions with an * should be completed.
Before we can finalise your Accident Claim Form, you will need to have your general practitioner (doctor) complete a Medical Certificate. The Medical Certificate is available in the Accident Forms download area of our website. Before you see your general practitioner please make a list of all of the areas of your body that are painful and sore as a result of the accident and make sure that your general practitioner specifically refers to each of the painful areas of your body on the medical certificate. The insurer will only pay for the treatment on the areas of your body that are specifically referred to on the Medical Certificate. Please also ensure that your general practitioner includes a referral on the Medical Certificate for physiotherapy, psychological counselling, orthopaedic specialist or any other medical specialist as appropriate.
We are currently in the process of updating this form. It will be back online shortly.