NEW Third Party Claim Form

By ticking I agree to the following
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.
Claimant's Declaration*
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
Are you an individual or a company?*
Company Name*
Salutation
First Name*
Last Name*
Contact No.
Email*
Occupation*
Address 1
Address 2
Town/City*
Country*
Are you VAT Registered?*
- Yes
- No
Enter your BIR Number
Enter your VAT Number*
Please provide Owner's Insurance Details
Policy No.*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Coverage Type
Was the owner driving the vehicle at the time of occurrence?*
- Yes
- No
Please fill in the details of the driver driving the vehicle
(If any information is unknown, please state unknown)
First Name*
Last Name*
Contact No.
DP No.*
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Relationship to Insured*
Other*

LOCATION OF OCCURRENCE
Address 1
Address 2
Town/City*
Country*
Was the accident reported to any police station?*
- Yes
- No
Please State badge number of Police Officer.
(If unknown, please state unknown)
Please state name of Police Station*
Please state name of Police Officer*
(If unknown, please state unknown)
First Last

OUR INSURED / DRIVER'S DETAILS
(If any information is unknown, please state unknown)
First Name*
Last Name*
Date of Birth
Date Format: DD slash MM slash YYYY
DP No.*
Vehicle Registration No.*
Policy No.
Contact No.
Email
Was the named policyholder driving the vehicle at the time of the accident?*
- Yes
- No
(If any information is unknown, please state unknown)
First Name*
Last Name*
Contact No.
DP No.*
Date of Birth
Date Format: MM slash DD slash YYYY
Email
Relationship to Insured*
Other*
Please give details of damage and extent*

DAMAGE TO THIRD PARTY'S VEHICLES
Were any other third party motor vehicles involved in the accident or occurrence?*
- Yes
- No
Third Party - Vehicle Details
Third Party - Vehicle Details
(If names are not known, please type unknown)
First Name*
Last Name*
Date of Birth
Date Format: DD slash MM slash YYYY

DP No.*
Contact No.
Email

Relationship with the owner?*
Other
Vehicle Registration Number
Does the owner / driver carry any form of automobile insurance?**
Yes
No
Don't Know
Policy No.
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Insurance Provider
Coverage Type
Please give details of damage and extent.*

THIRD PARTY PROPERTY DAMAGE DETAILS
Were any third party property involved in the accident or occurrence?*
- Yes
- No
Third Party - Vehicle Details
Property Damaged
(If unknown, please state unknown)
First Name*
Last Name*
Contact No.
Address 1
Address 2
Property Damaged*
Other*

Signature*
- Type-in Signature
- Digital Signature
Show Digital Signature
Signature*
Signature*
Date*
Date Format: DD slash MM slash YYYY
Would you like this form to be e-mailed to an additional person?*
- Yes
- No
Email*
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.