Motor Accident Claim

Please complete and submit the form below. Once this is done you will receive a confirmation email with your claim and we will be in touch shortly thereafter.

* Required Field

Insured

Insured First Name *
Insured Last Name *
Insured Contact *
Insured Contact E-Mail *
Insured Address (line 1)
Insured Address (line 2)
Insured Address (line 3)
Insured Tel (Work)
Insured Tel (Home)
Insured Tel (Cell)
Insured Policy No
Insured Vat No
Exact Type of Aircraft
Aircraft Reg No

Vehicle

Make of Vehicle
Model of Vehicle
Year of Vehicle
Tare
Gross Vehicle Mass
Vehicle Kilometers
Registration Number
Value of Vehicle
Year of Manufacture
Date of Purchase
Is The Vehicle Subject To Any Financing
Finance Company
Finance Company`s Address (Line 1)
Finance Company`s Address (Line 2)
Finance Company`s Address (Line 3)
Agreement Type

Damage Details

Damage To Own Vehicle
Estimate For Repairs
Repairer`s Name
Repairer`s Address (line 1)
Repairer`s Address (line 2)
Repairer`s Address (line 3)
Repairer`s Contact Number
Address for Inspection of Damagaed Vehicle (line 1)
Address for Inspection of Damagaed Vehicle (line 2)
Address for Inspection of Damagaed Vehicle (line 3)

Full Name
Address (line 1)
Address (line 2)
Address (line 3)
Tel (work)
Tel (home)
Tel (cell)
Driver`s Licence Number
Date of Issue
Place of Issue
Code of Licence
Type of Licence At Time of Accident
Did The Driver Have permission To Drive This Vehicle
Was The Driver In Your Employ
Does The Driver have Any Motor Insurance of Their Own
If Yes, What Is The Policy Number
If Yes, What Is The Insurance Company
State The Full Purpose of the Use of the Vehicle
Does The Driver Have Any Physical Disability

Passengers Details

Passenger No 1 - Contact Details (Name, Address, Contact Numbers)
Passenger No 1 - Details of injury
Passenger No 2 - Contact Details (Name, Address, Contact Numbers)
Passenger No 2 - Details of injury
Passenger No 3 - Contact Details (Name, Address, Contact Numbers)
Passenger No 3 - Details Of Injury
For What Purpose Where they Carried
Were They Employees At The time Of The Accident

Other Vehicles Details

First Vehicle - Registration Number
First Vehicle - Make
First Vehicle - Owner`s Full Name
First Vehicle - Owner`s Address
First Vehicle - Owner`s Contact Number
First Vehicle - Driver`s Full Name
First Vehicle - Driver`s Address
First Vehicle - Driver`s Contact Number
First Vehicle - Details of Damage
Second Vehicle - Registration Number
Second Vehicle - Make
Second Vehicle - Owner`s Full Name
Second Vehicle - Owner`s Address
Second Vehicle - Owner`s Contact Number
Second Vehicle - Driver`s Full Name
Second Vehicle - Driver`s Address
Second Vehicle - Driver`s Contact Number
Second Vehicle - Details of Damage
Third Vehicle - Registration Number
Third Vehicle - Make
Third Vehicle - Owner`s Full Name
Third Vehicle - Owner`s Address
Third Vehicle - Owner`s Contact Number
Third Vehicle - Driver`s Full Name
Third Vehicle - Driver`s Address
Third Vehicle - Driver`s Contact Number
Third Vehicle - Details of Damage

Damage to Property (other than vehicle)

Name of Owner
Address of Owner (line 1)
Address of Owner (line 1)
Address of Owner (line 3)
Details of Damage

Personal Injuries (other than in Insured Vehicle)

Name of Injured
Address of Injured (line 1)
Address of Injured (line 2)
Address of Injured (line 3)
Contact Number of Injured
Relationship to Accident (eg. driver, passenger etc.)
Name of Hospital
Details of Injury

Accident Description

Speed in Km/H (before)
Speed in Km/H (after)
Weather Conditions
Visibility
Road Surface
Were Vehicle Lights On
Describe Street-Lighting
Did You Give Any Indication (eg. Hooting etc.)
If Yes, State Details
Name of Police Officer Who Recorded The Details of the Accident
Name of Police Station
Case Reference No
Was The Driver Tested For Alchohol / Drugs
Describe The Accident