Alliance Leasing Insurance Claim Form

Please fill in the incident, driver and owner details below and press submit once complete. The form will be automatically emailed to GT Insurance. A copy of the completed form will be emailed to you at the email address provided in the form below.

Contact Details

Contact Name

Email Address *

Mobile Phone Number

Incident Details

Time of Incident

Date of Incident

Location of Incident

Your Vehicle Details

Make/Model

Registration Number

Year

VIN Number

If you have photos of your vehicle and/or the third party vehicle, please attach them here

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Current Location of your vehicle

Do you have dashcam footage of the incident?

Describe damage to your vehicle

Your Vehicle - Driver Details

Driver Full Name

Date of Birth

License Number

Number of Years Licensed

License Class

Is the licence current?

Alcohol and/or Drugs

Were drugs or alcohol consumed in the previous 12 hours?

Breathalyser / Blood test taken?

Police Attendance

Did Police attend the incident?

Police Report Number

Third Party Details

Name of Owner

Name of Driver

Address of Driver

Mobile Phone Number of Driver

Make/Model of Vehicle

Vehicle Registration Number

Third Party Vehicle Insurance Company

Describe damage to third party vehicle/property

Full Incident Description Required

Detailed Incident Description *

Draw a diagram of your incident (or upload below if not on touch device)

Clear drawing

Upload a drawing of the incident

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