Motor Accident Claim Form Please enable JavaScript in your browser to complete this form. – Step 1 of 7Policy No *INSURED’S NAME *Email *Address and (Day) Phone No.VEHICLE DETAILSMake Engine No. , Chassis NoModel and YearHorse power Kilometers CompletedRegistration No.Value Date of Purchase and price paidNextVEHICLE DETAILSIn Whose Name Is The Vehicle RegisteredDescription Of Damage To VehicleEstimate For Repairs Attach QuotationsProposed Repairer’s Name Address & Telephone Number Where Can Your Damaged Vehicle Be Inspected?NextDetails of DriverFull name *Occupation *AddressDate Of BirthDriving Licence I.D. No.No.DatePlace FullLearnerDriving Licence I.D. No.DatePlaceIf Learner Details Of InstructorState fully the purpose for which the vehicle was being usedWas he/she driving with your permission?YesNoWas he/she in your employ?YesNoDetails of any convictions for motoring offencesHas licence ever been endorsed?Yes NoHas he/she any physical disability?YesNoNextACCIDENT DESCRIPTION OF ACCIDENT/THEFTDate And TimePlaceClick the box for more details.Date / TimeDateTimePlaceSKETCH OF ACCIDENTAlong which road and in which direction was the vehicle travellingWas vehicle locked?SpeedWeather conditionsVisibilityRoad surfaceWidth of roadWhich vehicle lights were on?Street lightingClick on the boxes to answer all questions.State The Weather ConditionsVisibilityRoad SurfaceWidth of roadWhich vehicle lights were on?Street lighting?Was any warning given by you e,g, hooting, indicator etcWere there any witnesses if so give Name and Contact DetailsNextTHEFT Date and Time of Theft DateTimeFrom which address or exact location was the vehicle Where was the vehicle parked (garage/carport/driveway/parking area/road side or other place)When did you last see the vehicleWere all doors and windows closed and locked Where were the keys to the vehicle when the theft occurredWhen and how did you discover the theftWho is now in possession of the keys Vehicle, engine and chasiss no. If accessories stolen, provide full detailsAny special identification marks Police detailsName of Officer Station & Ref #Name of OfficerStation & Ref #Date reported to Police Station and name of StationWas driver tested for Alcohol or drugsNextPASSENGERS IN INSURED VEHICLEName and Occupation Address & Phone NoName and Occupation Address & Phone NoFor what purpose were they carried?Are they employees?YesNoOTHER VEHICLESRegistration No. MakeName and Address of Owner and Driver/Phone NoDamage and Third Party insurersRegistration No. MakeName and Address of Owner and Driver/Phone NoDamage and Third Party insurersNextPROPERTY OTHER THAN VEHICLESName and Address of Owner Details of DamageClick all the boxes to answer all questions.Name and Address of Owner Details of DamagePERSONAL INJURIES (OTHER THAN IN INSURED VEHICLE)Name of Injured Relationship to accident e.g. driver, passenger etc.Details of InjuryName of HospitalName of InjuredRelationship to accident e.g. driver, passenger etc.Details of InjuryName of HospitalNameSubmit