Policy and client Details

Name and Occupation:

Contact Person at Company (if applicable)

Vehicle Details

Make and Model:

Is Vehicle subject to Warranty or Motor Plan?

In whose name is the vehicle registered?

Damage to Vehicle

Damages are to own vehicle:

Estimate for Repairs:

Repairers Name, Address and Contact Details:

Where can your vehicle be inspected?

Is vehicle Drivable?

Driver details

Full Name:

Residential Address:


State full purpose for which vehicle was being used:

Was he/she in your employ?

Details of any convictions for motoring offences?

Details of previous accidents:

Passenger(s) in insured Vehicle Details


Residential Address:


For what purpose were they being carried?

Are they employees?

Third Party

Vehicle Make and Model:

Registration Number:

Name of Driver:

Residential Address:

Owner Details if different to above Driver:

Name of Owner:

Residential Address:

Property Other than Vehicles:

Name and Address of Owner:

Details of any Damage:

Independent Witnesses

Details of any Damage:

Details of any Damage:

Accident Details


Weather Conditions and Visibility:

Road Surface and Width of Road:

Vehicle light and Street Lighting:

Was any warning given by you? E.g. Hooting/Indicator?

Was Driver tested for drugs or alcohol?

Had the driver consumed any alcohol within 6 hours of the accident occurring?

Had the driver consumed any drugs within 6 hours of the accident occurring?

Description of Accident:

Details of Towing/Storage Company:

Where was your vehicle towed to?

Other important information not noted otherwise?

Sketch of Accident:

Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety signs or warning signs in the vicinity of scene of accident.

Upload Image of Drivers Licence:

E-mail Address:

Payment Method

You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name, branch and account number.

Name of Bank:

Name of Account:

Declaration and Signature

Insurers share information with each other regarding policies and claims with a view to prevent fraudulent claims and obtain material information regarding the assessment of risks proposed for insurance. Please refer to the Consent Clause on the policy schedule for more details in this regard.

NB: It is very important that you notify the insurers immediately you become aware of any impending prosecution, inquest or demand.

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.

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