MOTOR ACCIDENT REPORT CLAIM FORM
The information required in this form is sought in the bona fide belief that litigation may ensue, and for the purpose of furnishing to the solicitors of the company information to enable them to advise us on behalf of the insured in anticipation of litigation.
Please answer all questions fully and return forms without delay.
Policy No:
NAME OF INSURED
Surname:
First Name:
Middle Name:
Email:
Contact Address:
State:
Telephone/Mobile No:
Occupation:
Address at which vehicle is usually garaged:
Are you insured elsewhere in respect of this risk? YesNo
Brand:
Year of Manufacture:
H.P or CC:
Registration Number:
Chasis No:
Type of Body:
PURPOSE FOR WHICH USED AT TIME OF ACCIDENT
At the time of accident was the car used for: SocialDomesticPleasure
True mileage as at accident date if used for carriage of goods state nature of goods carried? SocialDomesticPleasure
Were the goods being carried for hire or reward? YesNo
State class of license held (e.g. Class A, B, or C):
Was a trailer attached? YesNo
If so, give Particulars:
IF USED FOR CARRIAGE OF PASSENGER (COACH ONLY):
Was the vehicle being used for stage, Express or Contract Services?: YesNo
IF USED FOR CARRIAGE OF PASSENGER (PRIVATE TYPE CARS ONLY):
Were passengers carried for private hire or public hire? YesNo
If not one of the above, state use at the time of accident:
DRIVER
Age:
Years of Experience:
Class of License:
Has she/he been concerned in any previous accidents?: YesNo
Date of Expiry:
If so, give details:
Does the driver have any physical defects? [select physical_defects "Yes" "No]
Has driver been prosecuted for any motoring offences? [select prosecuted "Yes" "No]
Is he in your employment? [select employed "Yes" "No]
If YES, in what capacity? And for how long?/label>
PARTICULARS OF ACCIDENT
Time:
Date:
Place:
State of weather. If dark, were your headlamps alight? What was the condition of the road?
Were any traffic lights operational at the scene of the accident?: YesNo
If yes, was the signal in your favour? YesNo
Was your vehicle on the main road?: YesNo
At what speed was your motor travelling at the time of the accident? What warning did your driver and others give?
Please give full description of accident and events leading up to it
WITNESSES OF ACCIDENT (IT IS IMPORTANCE ALWAYS TO OBTAIN NAMES AND ADDRESSES OF WITNESSES)
How many people were in the vehicle at the time of the accident?
Names and addresses of INDEPENDENT witnesses:
Witness Name
Witness Address
If No witnesses, please state reason:
Have you reported the accident to the police? YesNo
If YES give his number and station:
Did he witness the accident?: YesNo
Are the police taking any action as a result of the Accident? YesNo
Against whom:
DAMAGE TO INSURED’S MOTOR VEHICLE
If your Motor Vehicle has been damaged, please give full particulars
Probable Cost(N): YesNo
Repairer’s Tel. No
Please state when and where motor vehicle can be examined.
(If possible an estimate should accompany this form, but do not delay returning form if estimate is not yet obtained)
Names of any other parties concerned in the accident, and details of their claims (if any)
Name
Occupation
Address
Did they make any statement after the Accident? YesNo
If YES, what did they say?
Please give full details of their personal injury and damage to their property
Has notice of any claim been given to you?: YesNo
Were any passengers in your vehicles injured?: YesNo
(Any communication should be forwarded unanswered to the company at once)
If so, please give Name and Addresses and state extent of injuries:
Name):
If any person received treatment at scene of accident, or was taken to hospital give his/ her name and that of doctor and/or hospital
I/We hereby declare that the above statements and facts are true, and that I/we have not withheld from the Company any information within my/our knowledge connected with the Accident.
Signature:
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