Motor Accident Claims Notification Form

Insured's Name *

Email Address

Address

House No.

P.O Box

Phone Number *

Policy no(where branch the policy issued)

Renewal Date

Insured Vehicle

Make

Year Manufacture

Plate No(main/trailer) *

For what purpose was it being used

Carrying capacity and Type

Driver's name *

Occupation

Age

Phone Number *

Address

P.O Box

House No.

License No.

Grade

Expiry Date

Are you VAT Registered?

Details of accident

Date *

Time

Place

When was the Employer informed of the accident?

How far was it from near side?

What was the speed of the vehicle?

Was horn sounded?

YesNo

Were you in the Vehicle?

Description of the accident including conditions of road and visibility

Give names and addresses of owner and driver of other Vehicle(s) involved

Who in your opinion is responsible for the accident?

Do you hold more than one policy indemnifiying you in respect of the accident?

If so please give details

Does your driver get involved in an accident?

If so please give details

Please state if the other vehicle involved in this accident is insured with other company

Where particulars taken by police? If so, please give police station. Officers name and identification No.

Give names and addresses of persons in your vehicle

Name and address of independent witness

If not taken, please state why?

Details of damage to your vehicle

Details of damage to third party property and vehicle(s)

Details of injuries to persons(give names and address of such persons

I/We declar the foregoing particulars to be true and correct in every respect, and undertake to render the company every assistance in my/our power in dealing with the matter.

Date *

upload signature

No file chosen

Facebook
LinkedIn
Twitter
Instagram