MOTOR CLAIM FORM
Claim No:-
1.THE INSURED
Name:-
VAT No.:
Home Address:-
Tel.No.:
Business Address:-
Tel.No.:
Occupation:-
Date of Birth / ID.No:
2. THE POLICY
Policy No:
Renewal Date:-
Excess applicable : $
Coverage:
Insured Value : $
Is premium paid? if not,why not?
3. THE INSURED VEHICLE
Registration No: Year:
C.C. Engine No:
Mark & Model: Colour:
Chassis No.:
Is Vehicle: -- Left Hand Drive: Van:
Motor Cycle: Truck:
Special Licence:
Exactly what was vehicle being used for?
Name of Owner of Vehicle:
Was the vehicle being used  with owner's consent?
Specify any mortgage/hire purchase agreement on your vehicle:
How many passengers were being carried?
Were they fare paying?
If goods were being carried,state :
a) Owner
b)Description
4.THE DRIVER
Name:-
Male or Female:
Home Address:
Tel No.:
Business Address:
Tel No.:
Occupation:-
Date of Birth/ ID.No.:
Is the Driver employed by you?
State date of licence originally passed:
Driver's Licence No:(Please attach Photocopy)
Date of Issue:
Type of Licence:
Date of Expiry :
What is the relationship of the driver to the policyholder:
Has the Driver any motoring convictions/offences or licence endorsements/suspensions?(Give details)
Has the Driver had any previous accidents?(Give details)
Has the Driver ever been refused any type of insurance?
Has the Driver been drinking any alcohol / taking drugs?
Does the Driver own a vehicle?
Where is it Insured?
Reg. No.:
Has the Driver any physical infirmity, or defective vision or hearing, or lost a limb or any eye?
If yes, what?
5. THE ACCIDENT OR LOSS
Date:  Time:  Place:
Did the Police go to the scene?
Were measurements taken?
Police's Name/No:
Police Station to which reported:
Was either party warned for prosecution (If so whom)?
Was the road surface paved or unpaved?
Condition of road:
Weather Conditions:
What was your speed
a) before accident
b) at the time of accident:
Were your lights turned on?
Did you give any warning or signal?
Whom do you consider responsible for the accident?
6. DAMAGE TO VEHICLE
State damage to vehicle: (and indicate on drawing)
Point of Impact: Mark XXXX
Direction of Impact - Use arrows
Where can vehicle be inspected?
Is vehicle still in use?
Have you obtained an estimate for repairs? (if yes please provide copy)
7. PERSONS CONNECTED WITH THE ACCIDENT (AND PERSONAL INJURY)
Please provide the following information for all passengers in your vehicle:
Name/Address:
Tel. No.:
Age:
Nature of injuries / Where treated
Name/Address:
Tel. No.:
Age:
Nature of injuries / Where treated:
Please provide the following information for other persons injured or other witnesses to the accident:(Whether person(s) was Driver or Passenger or Other (Pedestrian etc.)
Name/Address:
Tel. No.:
Age:
Nature of injuries / Where treated
Name/Address:
Tel. No.:
Age:
Nature of injuries / Where treated:
8. OTHER VEHICLE OR PROPERTY CONNECTED WITH THE ACCIDENT
PARTICULARS VEHICLE 1
VEHICLE 2
VEHICLE 3
Registration No.:
Make & Model:
Name of Owner:
Address:
Name of Insurer:
Driver's Name:
ID.No.D.O.B
Address:
Name of Insurer:
Occupation:
Tel. No.:
Description of Damage:
Details of Damage to other Property
Name of Owner:
Point of impact: Mark XXXX Direction of impact - Use arrows
Kindly indicate by ticking the appropriate box, whether this report is only a notification or additionally, if you propose claiming under the policy.
ALL COMMUNICATIONS ABOUT THE ACCIDENT MUST BE IMMEDIATELY FORWARDED TO THE COMPANY . I/We hereby declare that to the best of my/our knowledge and belief,the foregoing statements are fully and truly made.
Date:-
Insured's Signature:
STATEMENT (to be completed by Driver)
Give details of the accident or loss as it occurred (in all cases of theft of the vehicle, please give Engine No.,
colour of vehicle, special features and date/time when notified to Police).
I/We hereby declare that the foregoing particulars by me/us are true in every respect:
Driver's Name:  ID. No.  Date:
Insured's Full Name:  ID. No. Date: