Motor Claims Insurance

Motor Insurance Claims

The Accident or Loss
The Accident or Loss
Date:*	Time:*	Place:*

The Accident or Loss
Did the police go to the scene?*
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?*
Did you give a warning signal?*
Was either party warned about prosecution? (if so, whom) *

Whom do you consider responsible for the accident?
Whom do you consider responsible for the accident? *

The Insured

Name:*
Telephone:*
Home Address:*

Driver

The Insured Vehicle

Reg. No.:*	Year:*	C.C.:*	Make:*	Model:*	Eng. No.:*	Chassis No.:*

Is the Vehicle
Is the Vehicle:*	Van	Motor Cycle	Truck	Left hand drive	Special License

Exactly what was the vehicle used for?
Exactly what was the vehicle used for? *

Was the vehicle being used with the owners consent? *

Specify any mortgage / hire purchase agreement on your vehicle: *

How many passengers were being carried?*

Were they paying a fare ?*

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).
*
Drivers Licence: (Upload a photo ID of your drivers licence in JPG format)
Photos: (Hold Ctrl button to select multiple photos.)
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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