Motor Accident Claim Form "*" indicates required fields 1INSURED2VEHICLE 3DAMAGE4DRIVER5PASSENGERS (INSURED VEHICLE)6OTHER PARTY7WITNESSES8ACCIDENT9 DECLARATION INSURER:POLICY NUMBER:INSUREDNAME*OCCUPATIONTELEPHONE NUMBER*ADDRESS VEHICLEIF VEHICLE IS SUBJECT TO A HIRE PURCHASE, CREDIT OR LEASING AGREEMENT,STATE NAME AND ADDRESS OF FINANCE COMPANY.MAKE*MODEL AND YEAR*COLOURVALUEREGISTRATION*TAREGROSS VEH. MASSKILOMETRES COMPLETEDPRICE PAIDDATE OF PURCHASE DD slash MM slash YYYY DAMAGEDAMAGE TO OWN VEHICLEESTIMATE FOR REPAIRS OR ATTACH QUOTATIONREPAIRER’S NAME, ADDRESS AND TELEPHONE NUMBERTELEPHONE NUMBERWHERE CAN YOUR DAMAGED VEHICLE BE INSPECTED?ATTACHMENT OF QUOTATION Drop files here or Select files Max. file size: 256 MB. DRIVERFULL NAME*ADDRESSTEL. NO.OCCUPATIONDATE OF BIRTH* DD slash MM slash YYYY DRIVERS LICENCEDRIVERS LICENCE NODATE DD slash MM slash YYYY PLACECODEFULL/LEARNERFullLearnerSTATE THE PURPOSE FOR WHICH THE VEHICLE WAS BEING USED.PrivateBusinessWAS HE/SHE DRIVING WITH YOUR PERMISSION?YesNoWAS HE/SHE IN YOUR EMPLOY?YesNoHAS HE/SHE ANY MOTOR INSURANCE ON OWN CAR? IF YES, STATE POLICY NUMBER AND COMPANYDETAILS OF ANY CONVICTIONS FOR MOTORING OFFENCES.HAS LICENCE EVER BEEN ENDORSED?YesNoDOES HE/SHE HAVE ANY PHYSICAL DEFECTS?YesNoDETAILS OF PREVIOUS ACCIDENTS. PASSENGERS (INSURED VEHICLE)PASSENGERS IN INSURED VEHICLENAMEADDRESSINJURY Add RemoveFOR WHAT PURPOSE ARE THEY BEING TRANSPORTED?ARE THEY EMPLOYEES?*YesNo OTHER PARTYDAMAGE TO OTHER VEHICLESREGISTRATION NO.MAKENAME, ADDRESS OF OWNER AND DRIVERDETAILS OF DAMAGE Add RemoveDAMAGE TO PROPERTY OTHER THAN VEHICLESNAME AND ADDRESS OF OWNERDETAILS OF DAMAGE Add RemovePERSONAL INJURIES (OTHER THAN IN INSURED VEHICLES)NAME OF INJUREDRELATIONSHIP TO ACCIDENT E.G. DRIVER,PASSENGER,ETC.DETAILS OF INJURIESNAME OF HOSPITAL IF APPLICABLE Add Remove WITNESSESWITNESSESNAME.ADDRESSTEL. NO Add Remove ACCIDENTDATE OF ACCIDENT DD slash MM slash YYYY TIME OF ACCIDENT Hours : Minutes AM PM AM/PM PLACE OF ACCIDENTSPEED - BEFORE ACCIDENT (KPH)SPEED - MOMENT OF IMPACT (KPH)WEATHER CONDITIONS?RainingSunnySnowingStormMistWindWaterVISIBILITY?RainingSunnyCloudyMistyClearDarkDaylightGlare from sunlightROAD SURFACE?TarredSandMuddyGravelPavedRockyWIDTH OF ROAD?Dual laneSingle laneMultiple lanesMultiple lanes (Highway)WHICH VEHICLE LIGHTS WERE ON?MineOther party/partiesMine & Other party/partiesNoneSTREET LIGHTING?YesNoWAS ANY WARNING GIVEN BY YOU?YesNoIN WHAT FORM ?HootingIndicatorHazardsBrakingPOLICE DETAILSPOLICE OFFICER AT SCENETRAFFIC OFFICER AT SCENEPOLICE STATIONSAP REFERENCE NOWAS THE DRIVER TESTED FOR ALCOHOL OR DRUGS?*YesNoRESULT OF TESTPositiveNegativeNot applicableDESCRIPTION OF ACCIDENTUPLOAD SKETCH OF ACCIDENT Drop files here or Select files Max. file size: 256 MB. DECLARATIONWE HEREBY DECLARE THE FOREGOING PARTICULARS TO BE TRUE IN EVERY RESPECT. LIIB AND THE APPLICABLE SERVICE PROVIDERS CAN PROCESS THE APPLICABLE PERSONAL INFORMATION FOR PURPOSES OF ADMINISTRATING THIS CLAIM. SIGNATURE OF DRIVER*DATE DD slash MM slash YYYY SIGNATURE OF INSURED*CAPACITY*InsuredParentProxySpouseSonDaughterDATE DD slash MM slash YYYY N.B. IT IS IMPORTANT THAT YOU NOTIFY THE INSURERS IMMEDIATELY YOU BECOME AWARE OF ANY IMPENDING PROSECUTION, INQUEST OR DEMAND.
