Name and Occupation:
Contact Person at Company (if applicable)
Make and Model:
Is Vehicle subject to Warranty or Motor Plan?
In whose name is the vehicle registered?
Damages are to own vehicle:
Estimate for Repairs:
Repairers Name, Address and Contact Details:
Where can your vehicle be inspected?
Is vehicle Drivable?
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:
For what purpose were they being carried?
Are they employees?
Vehicle Make and Model:
Name of Driver:
Owner Details if different to above Driver:
Name of Owner:
Property Other than Vehicles:
Name and Address of Owner:
Details of any Damage:
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?
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.
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:
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.
Send me a copy of this claim: