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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
CC
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?
Yes
No
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
*
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