Claims - Motor claim form - ICIB BROKERWEB

Full Name (or Company Name)

Contact Name

Address

Contact Number

Email address

Preferred method of contact?

Text

Phone

Please advise which ICIB Brokerweb branch you are serviced by. If you are unsure, please select 'Unsure/don't know'

Branch Name

Client Number (if known)

Broker Name (if known)

Insurer & Policy Number (if known)

Bank Account Name

Bank Account Number