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Motor Accident Claim Form

 

Please complete all questions as fully as possible
Policy Number

Insured Details

Insured’s Name Email
Telephone no Address
Occupation    

Vehicle Details

If vehicle is subject to a hire purchase, credit or leasing agreement, state name and address of finance company
Make Model
Year of Make Reg No
Chassis Number Purpose of Use
Financial Interest Value
Mileage    
Gross Mass Date Purchased
Purchase Price    

Damage Details

Damage to own vehicle Repair Estimate
Repairers Name, address and telephone number where can your damaged vehicle be inspected

Driver Details

Full Name Address
Occupation Date of Birth
Telephone No Drivers license Details ( no, date issued, place, category, full learner)
Purpose which vehicle was being used Was he or she driving with your permission
Was he or she your employee? Does the driver have any motor insurance on own car? if yes, state the policy number and company
Details for any convictions for motoring offences Has license ever been endorsed?

Passengers Details

Name Age Address Injury
For what purpose were they being transported Are they employees

Other Party Damages

Damage Type ( Vehicle / Property) Details or Vehicle / Property Name address of Owner Details of Damage

Personal Injuries

Name of Injured Relationship to injured e.g driver, passenger etc. Details of Injuries Hospital Details

Witness

Name Address
Telephone No    

Theft

Date Time
Place Was the vehicle left locked;
Who is now in possession of the keys Police station and reference number
Vehicle Make Vehicle Engine
Vehicle Chassis Number Vehicle Colour
Details of accessories stolen (if any)    

Accident Details

Date Time
Place Speed KM/h before accident
Speed KM/h moment of impact Weather conditions
Visibility Road Surfaces
Width of road Which vehicle lights were on?
Street lighting Was any warning given to you? hooting, indicator etc
Please specify Police Details Name of police officer who recorded the details of accident
Police station reference number    
  Description of accident
I hereby assign, transfer and cede to the insurer any and all claims or causes of action of whatsoever kind and nature which I now have, or may hereafter have, to recover against any person or persons as a result of the said occurrence and loss above- described. Also to recover on my behalf from such persons as a result of the occurrence and loss above –described. Also to recover on my behalf from such persons, my excess payment made a result of the said occurrence. I agree that the insurer may enforce the same in such manner as shall be necessary or appropriate for the use and benefit of the insurer, either in its own name or in mine. I will furnish such papers, information, or evidence as shall be within my possession or control for the purpose of enforcing such claim, demand, or cause of action.

NB it is important that you notify the insurers immediately you become aware of any impending prosecution, inquest or demand.