Motor Claim Form

If you have been part of an accident with your vehicle, you need to fill in an accident report. If you have an original, please send it to us or fax it to 971 677 807. You can also fill in the fomr below and send it to us over the Internet.
1. Date of
    accident:
Time: 2. Locality (place, city, street, country, etc.) 3. Injury(ies)
    even if slight
NO  YES 
4. Material damage to
     vehicle A and B
   5. Witnesses: Names, addresses, tel:
NO     YES
   5. Which Knight Insurance office do you use?
  6. Do you have a police report?
NO  YES 
 

VEHICLE A CIRCUMSTANCES VEHICLE B

   6. Insured / policyholder


First name 
Surname 
Address 
City 
Postal code 
Country 
Telephone 
Email 
"Parked / stopped"

   6. Insured / policyholder

First name 
Surname 
Address 
City 
Postal code 
Country 
Telephone 
Email 
"Leaving a parking
place / opening
the door"
"Entering a
parking place"
"Emerging from
a car park,
private ground,
from a track"
"Entering a car park, from private ground, a track"

   7. Vehicle

Make / type 
Registration nº 
Country of reg. 
If trailer, reg. nº 
Country of reg. 


"Entering a roundabout"


   7. Vehicle

Make / type 
Registration nº 
Country of reg. 
If trailer, reg. nº 
Country of reg. 

"Circulating a roundabout"

   8. Insurance company

Name 
Policy Nº 
Green Card Nº 
Valid from - to 
Agency 
Name 
Address 
City 
Postal code 
Country 
Telephone 
Email 

Does the policy cover material
damage to the vehicle? 
 NO   
YES

"Striking the rear of the other vehicle while going in the same direction and in the same lane"

   8. Insurance company

Name 
Policy Nº 
Green Card Nº 
Valid from - to 
Agency 
Name 
Address 
City 
Postal code 
Country 
Telephone 
Email 


Does the policy cover material
damage to the vehicle? 
 NO   
YES

"Going in the same direction but in a different lane"
"Changing lanes"
"Overtaking"
"Turning to the right"
"Turning to the left"

     9. Driver

First Name 
Surname 
Date of Birth 
Address 
Postal Code 
City 
Country 
Telephone 
Email 
Driving Licence Nº 
Category (A,B,...) 
Licence valid until 

"Reversing"

     9. Driver

First Name 
Surname 
Date of Birth 
Address 
Postal Code 
City 
Country 
Telephone 
Email 
Driving Licence Nº 
Category (A,B,...) 
Licence valid until 


"Encroaching on a lane reserved for circulation in the opposite direction"
"Coming from the right (at road junctions)"
"Had not observed a right of way sigh or red light"
      
 11. Visible damage to Vehicle A
` State numbers of boxes marked a
  11. Visible damage to Vehicle B

 12. Description of accident 
 

  14. My remarks         14. My remarks