MOTOR ACCIDENT CLAIM FORM

    Broker Name and Branch:

    Policy Name:

    Occupation or Type of Business:

    Your Email

    Cellular Telephone Number:

    Vehicle Details

    Year, Make and Model:

    Registration Number:

    VIN Number:

    Damage

    Please state how the damage occurred:

    Date and Time of damage:

    Declaration and Signature


    We the undersigned, declare the aforegoing particulars to be true in every respect. We understand that we will not be entitled to any benefits or indemnification of this claim, if the claim submitted is fraudulent in any manner whatsoever, whether submitted by ourselves or any of our agents.

    Name of Driver:

    Date:

    Name of Insured:

    Date:

    Send me a copy of this claim:

    Yes

    Click to confirm: