Claims Form | Synergy Accidents

Accident Claims Form

Please complete this form to the best of your knowledge to ensure that we can complete your claim swiftly and smoothly.

Full Name

Date of Birth

Email Address

Occupation

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Phone

Date of Accident

Time of Accident

Please Provide a Detailed Description of the Accident

Vehicle Registration Number

Vehicle Make & Model

Your Insurance Provider

Type of Cover

Policy Number

Location of Accident

Police Reference Number

(PCO/TAXI) Who is the vehicle owner?

(PCO/TAXI) Plating Area

Were you injured as a result of the accident?

Yes

How many passengers were in the vehicle at the time of the accident?

Were the passengers injured?

Yes

Third Party Driver Name

Third Party Vehicle Registration

Third Party Insurance Provider

Third Party Insurance Policy Number

Third Party Contact Number

Any Additional information about Third Party

Thanks for submitting!