Claim Form

Claim Form for Discovery Insure and Momentum Insure

Motor Claim
Vehicle*
Year Make & Model Registration Number
Driver Information*
Name of Driver ID Number Police Case Number
Driver's License*
Drop files here or
Describe where Damage is to your Vehicle*
Front, Back, Side
Full Description of Accident / Claim*
Pictures of Damage and Quote to Repair if available*
Drop files here or
Declaration*
I hereby Confirm that the above particulars to be true in every respect.

Property Loss Damage
Police Case Number
Describe fully how loss or damage occurred*
State how, (if applicable) entry was gained to the premises
Description & Value of Property*
Description of Property Date Acquired & Purchased From Value
Additional Information
Drop files here or
Quotes Received and/or photos of damage if applicable
Declaration*
I/We Confirm
I/we solemnly declare that I/we have suffered loss of or damage to the property enumerated on the description hereof and that the said property was in my/our possession immediately prior to the said loss/damage which occurred in the circumstances described above.

Description of Property	Date Acquired & Purchased From	Value

Motor Claim