INCIDENT DESCRIPTION

Our reference Date of incident Registration no.

NRA234963686 15 May 2023 NOREG1
Please provide the following information in upper case letters using black pen so we can assess your claim.

1. Do you know of any witness/es to this accident? Yes No If yes, provide details

First name Last name

St/Apt number Street name

Suburb/Town State Postcode

Witness contact number

2. Please confirm the date and time of the accident

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3. Please confirm where you were driving from and going to? (please include suburbs / locations)

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4. Do you drive in this area or on the road where the accident occurred regularly?

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5. Did you take any photos of the accident scene or obtain any video footage of the accident?
If yes, please attach all supporting documents and return to us. (Please contact us if you would
Yes No
like further information on how to send video footage).

6. Who do you believe is at fault? Why do you believe this person is at fault for the accident?

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7. Please give us a detailed description of the accident

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Insurance Australia Limited Please ensure all pages are completed

ABN 11 000 016 722 AFSL 227681 trading as NRMA Insurance Page 1 of 3
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8. Please draw a detailed diagram indicating street names, traffic signs, road markings and any significant land
markings. Please draw arrows to indicate direction travel of each vehicle and place an X on the points of damages
sustained to both vehicles:
Your car Other party's cars

Please also identify each vehicle with a letter: A, B, C etc

Make/Model Colour

Vehicle A

Registration

Name of Driver (if known): __________________________________________________________________________

Make/Model Colour

Vehicle B

Registration

Name of Driver (if known): __________________________________________________________________________

Make/Model Colour

Vehicle C

Registration

Name of Driver (if known): __________________________________________________________________________

Insurance Australia Limited Please ensure all pages are completed

ABN 11 000 016 722 AFSL 227681 trading as NRMA Insurance Page 2 of 3
 Make/Model Colour

Vehicle D

Registration

Name of Driver (if known): __________________________________________________________________________

I/We agree that, by submitting this form, the personal information I/we provide to NRMA Insurance in this form or
otherwise may be collected, held, used and disclosed in the manner set out in the NRMA privacy policy found at
www.nrma.com.au/privacy, including for processing this claim.

Your name

Date D D / MM / Y Y

Signature

Insurance Australia Limited Please ensure all pages are completed

ABN 11 000 016 722 AFSL 227681 trading as NRMA Insurance Page 3 of 3