MOTOR ACCIDENT REPORT FORM NEW

MOTOR ACCIDENT CLAIM FORM
Please Note it is necessary that great care should be taken in completing this form and the information given therein should be strictly accurate irrespective of whether it is in your favour or otherwise. You should not make any payment offer or promise of any payment or admit liability in anyway, as by so doing you may prejudice your position and make settlement a difficult matter.
1. Name
2. Policy No
3. Address
4. Tel. No.
5. Email
1. Motor vehicle.
Registration No
Make
Year of make
For what purpose was the vehicle being used
Did the insured give consent to driver of the vehicle

YesNo
2. Give details of person driving or had charge of your vehicle at the time of the accident and attached copy of Driver's License.
a. Name
b. License No.
c. Date Issue.

MonthDayYear
3. Please give the following details about the accident.
a. When did it happen? Date

MonthDayYear
Time

AM/PM Option
b. Where did it happen
4.In your opinion was the accident caused by you/driver?

YesNo
(i) If not, by whom?
(ii) If (4) is yes give name address and occupation of person/institution
5. Please give description of how the accident happened
6. (A) What is the damage to your vehicle?
(B) Where can the vehicle be seen?
(C) Name and address of your repairers
Name and address of persons injured and the extent of their injuries
7. State details of another vehicle involved.
a. Registration No./Model
Make
b. State name and address of driver of vehicle
c. State name and address of the owner and insurer of this vehicle
8. Did the Police?
(i) Wintness the accident

YesNo
(ii) Take any evidence or particulars?

YesNo
9. Please state witnesses if any.
(i)
(ii)
10. (A) Name and contact of Police Officer investigating the accident
(B) Police Station
11. Do you hold more than one policy indemnifying you in respect of the accident?

YesNo
I/We declare that the above statement is true in all respects to the best of My/Our knowledge and belief and I/We hereby leave in the hands of the company in accordance with the conditions of the policy the conduct of claims and litigation arising out of this accident and to which the policy applies, to deal with, to prosecute and/or settle as they think fit without further references to Me/Us and I/We undertake to give all such information and assistance as the company may require.
Driver's Signature

Clear
Insured's Signature

Clear
Date

MonthDayYear
Kindly attach the following documents.
Driver's License(Front & Back)

Cancelof
Pictures of accident vehicle showing vehicle number

Cancelof
Repair estimate

Cancelof
Police report/extract

Cancelof
Fire Service report

Cancelof
Should be Empty:

MOTOR ACCIDENT CLAIM FORM