Motor Claim Form

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Insured Details
Policy Holder Name
Address
Cellphone
Homephone
Employer
Occupation
VAT Reg. No.
Insured Coverage Details
Policy No.
Effective Date
date_range
Expiry Date
date_range
Type of Coverage
Sum Insured
Insured Vehicle Details
Vehicle Registration No.
Make and Model of Vehiclefor ex.: Hyundai Santa Fe
Year of Manufacturefor ex.: 2020
Chassis No.
Engine No.
Is the vehicle subject to any finance agreement?
If ‘YES’ give details.
If ‘NO’, in whose name?
Insured Driver Details
Name
Mailing Address
Employer
Occupation
Business Address
Cellphone
Homephone
Issue Date
date_range
Expiry Date
date_range
Date of Birth
date_range
Has the Driver been previously involved in an accident?
If ‘YES’ give details.
Has the Driver ever been charged with a Traffic Offence?
If ‘YES’ give details.
Was the Driver related to the Insured?
If ‘YES’ give details. For ex.: Employee / Relative / Friend
If employee, how long employed?
Where is the vehicle insured?
Policy & Certificate No.
Does the Driver own a Motor Car?
If ‘YES’ state Vehicle Reg. No.
Has the driver any physical impairment?If ‘YES’, give details
0 / 500
Accident Details
Loss Date
date_range
Time
access_time
Location
For what purpose was the vehicle being used?Please describe in details
0 / 500
Insured VehicleDirection of travel
Third Party VehicleDirection of travel
Speed (kmph)At the time of accident
Condition of road
Was horn sounded?
Was visibility good?
Was accident reported to police?
Date of Notification
date_range
Station
Receipt No.
Name of Officer
Rank of Officer
Officer Badge No.
Third Party Details
Owner's Name
Owner's Address
Cellphone
Homephone
Vehicle Registration No.
Make and Model of Vehiclefor ex.: Hyundai Santa Fe
Color of Vehicle
Displacement
Driver’s Name
Driver’s Address
Insurance Company
Policy & Certificate No.
Description of Damages and your estimate of the cost of repairs
0 / 800
Damages to insured's vehicle
Description of DamagesSeparate in multiple lines
0 / 500
Was estimate prepared?
Name of Repairer
Cost
Where can vehicle be inspected?
Was any person injured in accident?
Passengers in Trinre Insured Vehicle
Name
Age
Address
Details of Injury SustainedIf any
Physician or HospitalIf any
Passengers in Third Party Vehicle
Name
Age
Address
Details of Injury SustainedIf any
Physician or HospitalIf any
Draw sketch of accident


Please see the sample sketch shown above, using this as a reference, please try to mark the location your vehicle, the location of third party vehicle, pedestrians & other people concerned in this accident claim.

Please follow the steps below to mark positions on the blueprint and re-upload it for us to better evaluate your case.

Instructions

  1. Download the sketch blueprint here.
  2. You can sketch using your touchscreen device, or print a copy & do the sketching.
  3. If you do this on a device, you can save after sketching or if you printed a copy, just sketch on it with a pen, then take a photo of it.
  4. Upload it using the button below.

You're done.


Upload Documents
cloud_uploadUpload
In your opinion who was at fault?
Did such a person admit responsibility?
Give full details of accident
Details
0 / 1000

​Declaration *

I/We declare that the above statements and facts are true and that I/ we have not withheld any information within my/ our knowledge connected with the claim.

I agree that in such an eventuality the company can deny liability for all claims arising out of this accident.

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