Bonus Referral Program

Your Fault – Exclusive Cash Bonus Offer

If the accident was your fault, DON’T PAY EXCESS, we can help you. Our Bonus Referral Program will help you. You just need to refer the other party to us also and we can offer a cash bonus to yourself for bringing us the extra client.

You have two options in lodging the Bonus Referral Program Form with My Motor Claim. Either download the paper form, fill it in and email it back to the email address on the form. Or Fill in the online form below, of which you will also receive a PDF copy to your email address. If you haven’t heard from us within one hour please call us on 9363 8865.

Online Form

YOUR DETAILS (if it was your fault)

Name of Owner of Vehicle (on registration)

First Name *

Last Name *

Owner Address *

Phone *

Email *

License number *

Gender

• Male
• Female

VEHICLE DETAILS

Year

Make *

Model *

Registration

Registered for GST?

• Yes
• No

THE DRIVER DETAILS

(If the driver is the owner leave details below blank)

Driver Name

First Name

Last Name

Driver Address

Mobile

Email

License number

Gender

• Male
• Female

OTHER PARTY DETAILS (The other driver)

First Name *

Last Name *

Driver Address *

Mobile *

Email *

License number

Gender

• Male
• Female

VEHICLE DETAILS

Year

Make *

Model *

Registration

YOUR INSURANCE DETAILS (At Fault)

Insurance Company

Claim Number

ACCIDENT DETAILS

Date of loss/accident

Date of Loss and Time of Accident *

Date

Time

Location *

Please Provide a Brief Description *

INDEPENDENT WITNESS DETAILS

Full Name

Contact Number

Email

UPLOAD Photos/Documents (if available) *

Drag & Drop Files, Choose Files to Upload You can upload up to 5 files.

Drivers/Owners License:

Checkboxes *

• I Agree that By completing this form I am authorising My Motor Claim to act on my behalf in relation to a motor vehicle collision. And authorise the Release of Vehicle to the care of my representing agents, My Motor Claim.

Print Name *

(If claim is for a company vehicle, director full name and signing of this document is required)

Date *

Signature (Sign below) with Finger or Mouse *

Clear Signature

Submit