Home
Make Claim |
MOTOR CLAIM FORM
The issue of this form is not to be taken as an admission of liability
INSURED’S DETAILS
Full Name:
Policy Number:
Email:
Agent Name:
Mobile Number:
Address:
okon street
At the time of the accident, who drove the vehicle?
*
Insured
Insured’s Driver
Other
DRIVER’S DETAILS
Driver’s Name:
Phone Number:
Driver’s License Number:
Date of Expiry:
clear
Address:
VEHICLE DETAILS
Reg. No:
Make:
Year of Make:
Mileage:
Use(Commercial or private):
Commercial
Private
Is the vehicle at the repairer’s?
*
YES
NO
REPAIRER DETAILS
Name:
Phone Number:
Address:
DETAILS OF LOSS
Date of accident:
*
Time:
*
Place of Accident:
*
Road and weather conditions:
*
Full description of Accident:
*
Was the accident reported at the police station?
*
YES
NO
Who do you consider was at fault?
*
Myself
Third Party Driver
No one
Other
Type of loss:?
*
Own Damage
Vandalization
Negligent insured
Own Damage and Negligent insured
Negligent third party
Fire /Theft Total Loss
Fire Partial Loss
Property Third Party Damage only
THIRD PARTY DETAILS (Where the insured is negligent or where the third party is negligent)
Name:
Mobile:
Insurer:
