FILE A MOTOR VEHICLE CLAIM

We know that an insurance claim can be stressful. We will help you with friendly, step-by-step guidance. Please report your claim online by filling out this form, and we will get in touch with you shortly with the details about your claim.

1. DETAILS OF INSURED

Full name: Address:

Tel/Cell Number(a) Private: (b) Business: Occupation/Profession:

Email Address*:

2. PERSON DRIVING AT THE TIME OF THE 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, how long employed: Was he/she driving with thw insured's permission?

3. VEHICLE CONCERNED

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

4. USE OF VEHICHLE

For what purpose was the vehicle used (if business use state exact nature of business): Number of passengers being carried:

Were trade goods being carried? Number of trailers attached to the vehichle: For motorcylces only: was a pillion passenger being carried?

Was a side car attached:

5. PARTICULARS OF THE ACCIDENT

Date of accident: Time: Place of accident:

Speed of vehicle: (a) Immediately before the accident: (b) At the moment of impact: How far from the edge of the road?

Was the driver sober: Was warning of approach given? Were your lights on? Were you in the vehicle?:

if not, when was the accident reported to you: Who in your opinion was to blame?: What was the weather condition:

6. DAMAGE TO INSURED'S VEHICLE

Details of damage: Where can it be inspected:

Repair quotations obtained from: (a): Tel/Cell No: (b): Tel/Cell No: (c): Tel/Cell No:

7. DAMAGE TO OTHER VEHICLES OR PROPERTY

Name and address of owner: Make: Reg Number:

Details of damage: Did any other party disclose his/her insurance?

if so, name of company: What is your estimate of repair costs to the other persons property:

8. INJURIES TO PERSONS

Name: Contact details: Nature of injury:

Name: Contact details: Nature of injury:

Name: Contact details: Nature of injury:

If injured person was moved to hospita, state name of hospital:

Do you have avy reason to believe that a claim will be made against you in respect of injuries to persons or damage to vehicles or other property or do you intend to make such a claim against other parties? if so please give particulars:

9. NAME AND ADDRESS OF ALL WITNESSES

Passengers

Name: Contact details:

Name: Contact details:

Independent

Name: Contact details:

Name: Contact details:

Police officer who witnessed or took particulars of the accident

Name: Contact details:

Is there any other policy covering damage caused in this accident?:

10. CIRCUMSTANCES OF THE ACCIDENT

Attachments if available:
Police report:
Drivers licence: