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.
NAME OF INSURED
PURPOSE FOR WHICH USED AT TIME OF ACCIDENT
IF USED FOR CARRIAGE OF PASSENGER (COACH ONLY):
IF USED FOR CARRIAGE OF PASSENGER (PRIVATE TYPE CARS ONLY):
PARTICULARS OF ACCIDENT
WITNESSES OF ACCIDENT (IT IS IMPORTANCE ALWAYS TO OBTAIN NAMES AND ADDRESSES OF WITNESSES)
Names and addresses of INDEPENDENT witnesses:
DAMAGE TO INSURED’S MOTOR VEHICLE
(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)
(Any communication should be forwarded unanswered to the company at once)
If so, please give Name and Addresses and state extent of injuries:
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.