Insured Motor Claim Form - Best Insurance Company Trinidad & Tobago

Claimant

Claimant's Disclaimer*

I declare that to the best of my knowledge and belief, the information to be provided by me is true and correct, and that I will not withhold any information connected with this claim being filed by me.

I understand that Gulf Insurance Limited requires the information in this form as part of its review of the claim being filed by me.

I am aware that failure by me to provide information that is true and correct, or which I believe may not be true and correct, or withholding information relevant to this claim may result in Gulf Insurance Limited denying or voiding my claim, and/or pursuing criminal actions and/or civil proceedings against me in accordance with the relevant laws of the land.

Insured

Are you an individual or a company?*

Salutation

First Name*

Last Name*

Company Name*

Policy No.

Contact No.

Email*

Address 1

Address 2

Town/City*

Country*

Coverage Type*

Is the vehicle mortgaged?*

YesNo

Details of Mortgage*

Are you VAT Registered?*

YesNo

Enter your VAT details*

Insured vehicle details

Vehicle Registration Number*

Insured Value

Make*

Model*

Yr. of Manufacture

The accident or occurrence

Description*

Date of Accident*

Hour*

Minutes*

AM/PM*

Car Speed*

Speed Unit*

Weather Conditions*

Location of occurrence

Address 1

Town/City*

Address 2

Country*

Please state exactly what the vehicle was being used for at the time of the accident*

Other*

Was any warning given before the accident?*

YesNo

Please explain the warnings given*

Was the accident reported to any police station?*

YesNo

Please State badge number of Police Officer*

Please state name of Police Station*

Please state name of Police Officer (If unknown, please state unknown)

Last Name

In your opinion, who was at fault?*

Damage to insured's vehicle

Details of damage and extent*

Address 1

Address 2

Town/City*

Country*

Insured driver details

Was the insured driving the vehicle at the time of occurrence?*

YesNo

(If any information is unknown, please state unknown)

First Name*

Last Name*

Contact No.

DP No.*

Date of Birh*

Email

Relationship to Insured*

Other*

Does the driver have any other local motor vehicle insurance?*
YesNo

Policy No.

Insurance Provider*

Has the insured/driver ever been convicted by a court of any offense in connection with a motor vehicle?*

YesNo

Please provide details of conviction*

Were any intoxicating beverages or drugs consumed by insured/driver within 12 hours of the incident?*

YesNo

Please provide details*

Has the insured/driver any physical impairment?*

YesNo

Please provide details*

Were there any occupants in the vehicle?*

YesNo

Occupant Details

(If unknown, please state unknown)

First Name*

Last Name*

Contact No.

Injuries

Were any injuries sustained in the accident?*

YesNo

Person Injuries

First Name*

Last Name*

Contact No.

Approximate Age*

Occupation

Address 1

Address 2

Town/City

Country

Nature and extent of injuries*

Details of medical attention sought*

Third party motor vehicle details

Were any third party motor vehicles involved in the accident or occurrence?*

YesNo

Third Party - Vehicle Details

(If names are not known, please type unknown)

First Name*

Last Name*

Date of Birth*

DP No.*

Contact No.

Email

Relationship to Insured*

State other relation*

Vehicle Registration Number

Does the owner/ driver carry any form of automobile insurance?*

YesNoDon't Know

Policy No.

Insurance Provider*

Coverage Type*

Please give details of damage and extent*

Third party property damage details

Was any third party property damaged in the accident?*

YesNo

First Name*

Last Name*

Contact No.

Address 1

Address 2

Property Damaged*

Other*

Witnesses

Were there any witnesses to the accident?*

YesNo

Witness

First Name*

Last Name*

Contact No.*

Address 1

Address 2

Town/City

Country

Signature*
Type-in SignatureDigital Signature

Signature*

Digital Signature*

Disclaimer

By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.

Date*