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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.

Third party owner / driver details


Please provide Owner's Insurance Details

Please fill in the details of the driver driving the vehicle
(If any information is unknown, please state unknown)

Third party vehicle details

The accident or occurrence

Location of occurrence


Damage to third party's vehicle



Our Insured / Driver details

(If any information is unknown, please state unknown)


(If any information is unknown, please state unknown)

Third party motor vehicle details


(If names are not known, please type unknown)

YesNoDon't Know

Third party property damage details




Type-in SignatureDigital Signature

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.