Wiggle Accident Claim

Your details

Policy number
(If you have it handy)

Name of insured*

Address*

Best phone number*

Email*

Preferred method of contact*

Incident details

Bike make and model*

Serial number of bike*

Date of incident*

Time of incident*

Where did the incident occur?*

Please describe what happened:*

Where is your bike now?*

Were there any other parties involved?*

If yes, how were they involved?

Name of person

Contact number

Make and model of car/bicycle

Rego No / Serial No:

Name of their insurer:

Applicable claim number:

Any witnesses?

Witness name

Witness contact number

Police report
Please provide the police report details if applicable:

Police station

Date reported

Time reported

Police report number

Injuries?

Were you injured in the accident?*

If yes, please provide details

Other Insurance*
Do you have other insurance like home and contents?

Yes No

Name of Insurer

Previous claims history

Have you had any bike, home or contents claims in the past 3 years?

If yes, please provide details of these claims:

Your local bike shop

Store name*

Contact name*

Phone number*

Photos of the damage
Please upload clearly focused photos of the following:
- Damage to your bike
- Photo of the whole bike in its current state

File Attachments*

You can upload multiple photos before submitting the claim

Briefly describe the damage to your bike:

Declaration*
* I hereby certify that the information given in the form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I understand that this claim may be refused if information is untrue, inaccurate and concealed.

* I authorise Wiggle or its agents to give to, or obtain from, other insurers or any insurance reference bureau, any information to this claim or any other claim made by me or any insurance held by me.

Send me a copy of my responses

Email address