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Motor Accident Claim Form
Please complete all questions as fully as possible
If vehicle is subject to a hire purchase, credit or leasing agreement, state name and address of finance company
Year of Make
Purpose of Use
Damage to own vehicle
Repairers Name, address and telephone number
where can your damaged vehicle be inspected
Date of Birth
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?
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
Name of Injured
Relationship to injured e.g driver, passenger etc.
Details of Injuries
Was the vehicle left locked;
Who is now in possession of the keys
Police station and reference number
Vehicle Chassis Number
Details of accessories stolen (if any)
Speed KM/h before accident
Speed KM/h moment of impact
Width of road
Which vehicle lights were on?
Was any warning given to you? hooting, indicator etc
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.