Did any one witness the incident? If yes please provide their details below including full name and contact details

You’re are almost done: Please complete the Declaration below and just click “Submit these claim details” and we’ll take it from there.

I hereby declare that to the best of my knowledge and belief that the information I have provided is correct and request you to deal on my behalf with any claims which may arise out of the accident in accordance with the terms and conditions of the Policy.

I authorize you and your attorneys-at-law on my behalf to make such admissions and settlements and give such consents as you consider necessary for the disposal of such claims and any litigation arising therefrom.