FILE A MOTOR VEHICLE CLAIM

2. PERSON DRIVING AT TIME OF ACCIDENT

Full name: Tel/Cell Number: Address: Occupation: Driving licence No: Inspected by: Date and Place of issue: Date of original licence: Class of licence: Age: Is he/she in insured's service? If so, employment duration: Was he/she driving with insured's permission?

3. VEHICLE CONCERNED & USE

Make: Reg. Number: HP: Carrying capacity: Who is the owner: Year of make:

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Exact purpose of Use during event: Number of passengers: Were trade goods carried? Number of trailers attached: Pillion passenger carried? (Motorcycles): Sidecar attached?

4. PARTICULARS OF THE ACCIDENT

Date of accident: Time: Place of accident: Speed immediately before accident: Speed at moment of impact: Distance from edge of road: Was driver sober? Was warning of approach given? Were lights active? Were you in the vehicle? If out, when was it reported to you? Who in your opinion was to blame? Weather conditions:

5. DAMAGE TRACKING (OWN & THIRD PARTY)

Details of damage to insured vehicle: Where can it be inspected? Repair quotations description: Firm A & Tel: Firm B & Tel:

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Third Party Owner Name/Address: Third Party vehicle Make & Reg: Details of Third Party Damage: Did other party declare insurance info? If yes, Company Name & Cost Estimate:

6. INJURIES, WITNESSES & UPLOADS

Injured Person A (Name, Contact, Injury): Injured Person B (Name, Contact, Injury): If moved to medical facility, State Hospital name: Reason to expect external liability claims against you?

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Witness Accounts

Passenger Witness 1 (Name & Contact): Independent Witness 1 (Name & Contact): Police Officer details (Name & Station Contact): Insurance Policy Info Reference:

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10. CIRCUMSTANCES OF ACCIDENT Description:

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Police Report Document (PDF/DOC): Drivers Licence Copy (PDF/DOC):