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Motor Insurance Claims

(Please fill in all the information requested before submitting the form)

Fields mark (*) Are fields

  The Accident or Loss
Date:* Time:* Place:*
Did the police go to the scene?* Yes No
Policeman name / number:*
Police Station to which reported: *
Weather Conditions:*
Condition of road:*
Vehicle road condition before accident:*
Vehicle speed at collision:*
Were your lights turned on?* Yes No
Did you give a warning signal?* Yes No
Was either party warned about prosecution? (if so, whom) * Yes No
Whom do you consider responsible for the accident? *
  The Insured
Name:*
Telephone:*
Home Address:*
  The Insured Vehicle
Reg. No.:* Year:* C.C.:* Make:* Model:* Eng. No.:* Chassis No.:*
Is the Vehicle:* Van Motor Cycle Truck Left hand drive Special License
Exactly what was the vehicle used for? *
Was the vehicle being used with the owners consent? * Yes No
Specify any mortgage / hire purchase agreement on your vehicle: *
How many passengers were being carried?*
Were they paying a fare ?* Yes No
OTHER VEHICLE OR PROPERTY CONNECTED WITH THE ACCIDENT
Particulars Vehicle 1 Vehicle 2 Vehicle 3
Reg. No.:
Make & Model
Insurance Company
Name of Owner
Address
Name of Insured
Tel. No.
Driver Name
Address
Tel. No.
Damage:
Please state the details of the accident as it occurred (in all cases of theft of vehicle, please advise: Engine number, colour of vehicle, specific features and date/time when noticed to Police).
*
I/We hereby declare that the foregoing particulars by me/us are true in every respect:*
Drivers Signature* I.D No.* Date*
I/We hereby declare that the foregoing particulars by me/us are true in every respect:*
Insured's Signature* I.D No.* Date*
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