Motor Claim Form

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Motor Claim Form

Step 1 of 8

12%

PLEASE FURNISH ALL DETAILS USING THIS REPORT

**You are required to upload a DIAGRAM OF ACCIDENT**

INSURED:

Name(Required)

Address(Required)

Telephone No. (Home)(Required)

Telephone No. (Business)(Required)

MOTOR VEHICLE DETAILS

Make/Model…(Required)

Year(Required)

Please enter a number greater than or equal to 1900.

Reg. NO.(Required)

Name of Owner(Required)

Address(Required)

For what purpose was the vehicle being used(Required)

Name of Hire-Purchase Company (if any)

Amount Outstanding

DRIVER DETAILS

Driver’s full name(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Driver’s License No(Required)

Date & Place of Issue(Required)

Full or Provisional(Required)

Full

Provisional

Class(es)(Required)

Endorsements

Yes

No

When & Why(Required)

DATE & TIME OF ACCIDENT

Date of Accident(Required)

MM slash DD slash YYYY

Time(Required)

Hours

:

Minutes

AM/PM

Place of Accident(Required)

Describe weather conditions(Required)

Describe Road Condition(Required)

DESCRIPTION OF ACCIDENT

Who authorised use of Motor Vehicle(Required)

Why?(Required)

Speed(Required)

If object collided with was moving, what direction was it going?

Police station reported to(Required)

IR/TAB NO:(Required)

If matter was not reported to police, please advise reason(Required)

Number of persons in the insured motor vehicle(Required)

Please enter a number greater than or equal to 0.

PERSONS INJURED

Name

Address

Apparent Age

Relationship to Insured

Occupant of insured’s car (Yes/No)

Occupant of other car (Yes/No)

Pedestrian (Yes/No)

Nature and extent of injuries(Required)

If medical attention was rendered give name of doctor:

Where were the injured taken(Required)

DAMAGE TO PROPERTY OF OTHERS

Name of owner(Required)

Address(Required)

Kindly of property (If motor vehicle give make & Year):(Required)

Nature and extent of damage:(Required)

Estimated cost of repair:(Required)

Has claim been made?(Required)

Yes

No

Is claimant insured?(Required)

Yes

No

Claimant’s License Number(Required)

Name of insurance company(Required)

IT IS IMPORTANT TO COMPLETE BOTH SIDES OF THIS REPORT FORM

Whenever possible please obtain names and addresses of witnesses, bystanders or persons in the immediate vicinity who may have seen the accident or heard statements made by any of the persons involved.

WITNESSES NAMES & ADDRESSES

NAME

ADDRESS

DAMAGE TO INSURED VEHICLE

Repairs should only commence with the company’s consent.

Parts damaged and extent:(Required)

Estimated cost of repairs(Required)

Name of party who caused the damage:(Required)

Address(Required)

Is he insured?(Required)

Yes

No

Name of company if known

Where can the vehicle be seen?(Required)

DRIVER’S ACCOUNT OF LOSS

Driver’s Statement(Required)

Date(Required)

MM slash DD slash YYYY

DIAGRAM OF ACCIDENT(Required)

Max. file size: 8 MB.

GIVE STREET NAMES, DIRECTION AND LOCATION OF OBJECTS CONCERNED

DECLARATION

Name of Insured(Required)

Date(Required)

MM slash DD slash YYYY

I/We hereby declare and warrant that all the information, including any document(s) that I/We have provided herein, is true and correct and that I/We have not withheld from the Company any information within my/our knowledge in connection with the accident or loss. I/We further acknowledge that the information I/We have provided herein will induce the insurer to act thereon and accordingly declare that by signing below, I/We warrant that the information I/We have provided herein, in its entirety, is true and correct.(Required)

I do

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