Motor Accident Claim Form "*" indicates required fields 1INSURED2VEHICLE 3DAMAGE4DRIVER5PASSENGERS (INSURED VEHICLE)6OTHER PARTY7WITNESSES8ACCIDENT9 DECLARATION URLThis field is for validation purposes and should be left unchanged.INSUREDPOLICY NUMBER:Name and occupation*AddressTelephone/ Cell Number*E-mail address Please enter your email if you would like a copy.Identity number / VAT number VEHICLEMAKE*TAREGROSS VEH. MASSKILOMETRES COMPLETEDREGISTRATION*VALUEMODEL AND YEAR*DATE OF PURCHASE DD dash MM dash YYYY If vehicle subject to Hire Purchase, Credit or Leasing Agreement, state name, address and account number of Finance CompanyIn whose name is the vehicle registered? DAMAGEDamage to own vehicleEstimate for repairs or attach quotationRepairer's name, address and telephone numberWhere can your damaged vehicle be inspected?ATTACHMENT OF QUOTATION Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB. DRIVERFull Name*Residential AddressOccupationDate of Birth and Identity NumberDRIVERS LICENCEDRIVERS LICENCE NODATE DD dash MM dash YYYY PLACECODEFULL/LEARNERFull LicenseLearners LicenseState fully the purpose for which vehicle was being usedWas he/she driving with your permission?YesNoWas he/she in your employ?YesNoHas he/she any motor insurance on own car? If yes, state Policy number and CompanyDetails of any convictions for motoring offencesHas licence ever been endorsed?YesNoHas he/she any physical defects?YesNoDetails of previous accidents. PASSENGERS (INSURED VEHICLE)PASSENGERS IN INSURED VEHICLENameResidential addressInjury Add RemoveFor what purposes were they carried?Are they employees?*YesNo OTHER PARTYPERSONAL INJURIES (OTHER THAN IN INSURED VEHICLES)Name of InjuredRelationship to accident eg. driver, passenger etcDetails of injuriesName of Hospital if applicable Add RemoveDAMAGE TO OTHER VEHICLESRegistration No.MakeName & address of owner and driverDetails of damage Add RemoveDAMAGE TO PROPERTY OTHER THAN VEHICLESName and address of ownerDetails of damage Add Remove WITNESSESName, Address and Telephone No.Name, Address and Telephone No. ACCIDENTDATE OF ACCIDENT DD dash MM dash YYYY TIME OF ACCIDENT Hours : Minutes AM PM AM/PM PLACE OF ACCIDENTSPEED - BEFORE ACCIDENT (KPH)SPEED - MOMENT OF IMPACT (KPH)WEATHER CONDITIONS?RainingSunnySnowingStormMistWindWaterVISIBILITY?RainingSunnyCloudyMistyClearDarkDaylightGlare from sunlightROAD SURFACE?TarredSandMuddyGravelPavedRockyWIDTH OF ROAD?Dual laneSingle laneMultiple lanesMultiple lanes (Highway)WHICH VEHICLE LIGHTS WERE ON?MineOther party/partiesMine & Other party/partiesNoneSTREET LIGHTING?YesNoWas any warning given by you, eg. hooting, indicators etc?POLICE DETAILSName of Police/Traffic officer who recorded details of accidentPolice station and reference numberWas driver tested for alcohol or drugs?*YesNoDescription of accidentSKETCH OF ACCIDENT (if necessary use separate page) Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety signs, or warning signs in vicinity of scene of accident.SKETCH OF ACCIDENT Drop files here or Select files Max. file size: 256 MB, Max. files: 10. DECLARATIONWe hereby declare the foregoing particulars to be true in every respect. Signature of Driver*Date DD dash MM dash YYYY Signature of Insured*Capacity*InsuredParentProxySpouseSonDaughterDate DD dash MM dash YYYY N.B. IT IS IMPORTANT THAT YOU NOTIFY THE INSURERS IMMEDIATELY YOU BECOME AWARE OF ANY IMPENDING PROSECUTION, INQUEST OR DEMAND.
