Wiggle Accident Claim
Your details
Policy number
(If you have it handy)
Name of insured
*
Address
*
Best phone number
*
Email
*
Preferred method of contact
*
Email
Phone
Incident details
Bike make and model
*
Serial number of bike
*
Date of incident
*
Time of incident
*
00:00
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
Where did the incident occur?
*
Please describe what happened:
*
Where is your bike now?
*
Were there any other parties involved?
*
Yes
No
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
00:00
01:00
02:00
03:00
04:00
05:00
06:00
07:00
08:00
09:00
10:00
11:00
12:00
13:00
14:00
15:00
16:00
17:00
18:00
19:00
20:00
21:00
22:00
23:00
Police report number
Injuries?
Were you injured in the accident?
*
Yes
No
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?
Yes
No
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
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