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NEW Insured Motor Claim Form

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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?*
- Yes
- No
Please explain the warnings given*
Was the accident reported to any police station?*
- Yes
- No
Please State badge number of Police Officer.*
Please state name of Police Station*
Please state name of Police Officer
(If unknown, please state unknown)
First Last
In your opinion, who was at fault?*

INSURED DRIVER DETAILS
Was the insured driving the vehicle at the time of occurrence?*
- 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*
Does the driver have any other local motor vehicle insurance?*
- Yes
- No
Policy No.
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Insurance Provider*
Has the insured/ driver ever been convicted by a court of any offence in connection with a motor vehicle?*
- Yes
- No
Please provide details of conviction*
Were any intoxicating beverages or drugs consumed by insured/driver within 12 hours of the incident?*
- Yes
- No
Please provide details*
Has the insured/driver any physical impairment?*
- Yes
- No
Please provide details*
Was the driver operating the vehicle with the insured's permission?*
- Yes
- No
Were there any occupants in the vehicle?*
- Yes
- No
Occupants
Occupant Details

(If unknown, please state unknown)
First Name*
Last Name*
Contact No.

THIRD PARTY MOTOR VEHICLE DETAILS
Were any 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.*

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