What date did the incident take place?

What time did the incident occur?

If you don't know the exact time, please estimate it using the options above

Where did the incident take place? Please provide as much information as possible, such as a specific address or a nearby landmark, if possible.

What's your full name?

What's your vehicle registration?

Your contact phone number

Please select the option that best describes your claim

Please select the option that best describes the incident

Please select the option that best describes the incident

Please select the option that best describes the incident

Please select the option that best describes the incident

Please select the option that best describes the incident

Please select the option that best describes the incident

Please select the option that best describes the incident

Was your vehicle damaged in the incident?

Are you able to drive your vehicle?

Who was driving your vehicle at the time of the incident?

What's your date of birth?

dd/mm/yyyy

Please select your licence type

What country is your licence from?

What type of licence is it?

What date did you enter New Zealand?

How long have you held a driver’s licence?

What country is their licence from?

Was the substance consumed either prescription or over the counter medication and if so, was it taken in accordance with medical/pharmacy advice and the instructions on the packaging?

Please provide further details about the drugs or medication taken or the type and amount of alcohol consumed

Did the police attend the incident or was a report made?

All information you provide must be true, complete and correct - if it isn't this claim may not be accepted. We may share information with, and collect information from, other parties, including the Insurance Claims Register. Do you understand and agree

Please note that selecting 'No' means we will need to contact you for more information.