Claim Form Preview Motor Claim Form Step 1 of 8 12% CLAIMER DETAILSName(Required) First Last Physical Address(Required) Postal Address(Required) Email Address(Required) Telephone NumberCell Number(Required) VEHICLE & DRIVER DETAILSName of driver at time of loss(Required) First Last Driver is(Required) Owner Owner's Employee Owner's Relative/Friend Did you authorize the journey?(Required) Yes No State fully what the vehicle was being used for(Required)State fully what the vehicle was being used forComing FromGoing ToPurpose of TripWhen was the driver licensed to drive?(Required) DD slash MM slash YYYY Vehicle Type(Required) Registration Number(Required) Makers Number(Required) Class of Vehicle(Required)MotorcyclePrivate MotorVanSUVCaravanPlantHorse (truck)TrailerBus / MinibusHas the driver been convicted of a driving offence?(Required) Yes No Current NCBsGive details & dates of driving offence(s)(Required)License Number(Required) License date of issue(Required) DD slash MM slash YYYY Has the driver's license been endorsed(Required) Yes No If there is a hire purchase or other agreement, how much is outstanding?Did the motorcycle have a side car attached?(Required) Yes No Was there a pillion passenger?(Required) Yes No CIRCUMSTANCES OF ACCIDENT/LOSS/DAMAGEDate(Required) DD slash MM slash YYYY Time(Required) Hours : Minutes Place(Required)What was your speed?(Required)in KM/hWeather Condition(Required)ClearRainingThunderstormRain with HailWind and DustOther (Define)Describe Weather Conditions(Required) Visibility(Required)Full VisibilityModerate VIsibilityLow VisibilityVery Low VisibilityRoad Surface(Required)DryWetSlipperyDescription of accident/theft(Required)Upload sketch of accident(Required)Scan or take a picture of sketch to upload here Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB. Full extent of damage(Required)Damaged vehicle location(Required) Was the vehicle towed from the scene?(Required) Yes No Provide details of towing company(Required) Have you given instructions for repairs to be done?(Required) Yes No Estimated cost of repairs(Required)Enter number onlyIf tyres were damaged or stolen, state make and mileage done INJURIES TO OCCUPANTS OF THE VEHICLEWere the passengers being carried in/on your vehicle for hire or reward?(Required) Yes No Was any injury sustained by the driver or passenger in your vehicle?(Required) Yes No Give details of names of the injured persons, details of injuries and hospital coveyed to if applicable.(Required)Are any of the passengers in the vehicle your employee?(Required) Yes No DETAILS OF THIRD PARTIESFull Name(Required) First Last Contact Number(Required)Vehicle Registration Number(Required) Has notice of any claim been given to you?(Required) Yes No WITNESSESDetails of PassengersFill in the name and address of the passengers. (Click + to add more people). Leave blank if not applicable.NameAddress Add RemoveGive details of fault made by witness or drivers if any(Required)Name of Police Station case reported to. Include IR Number.(Required) Was driver tested for alcohol or drugs?(Required) Yes No Describe alcohol/drug test outcome(Required) SUPPORTING DOCUMENTSCopy of driver's license(Required) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB. Police Report(Required) Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB. Details of 3rd Party, if any Drop files here or Select files Accepted file types: jpg, png, pdf, Max. file size: 64 MB. At least 3 repair quotations from reputable garages(Required) Drop files here or Select files Accepted file types: jpg, png, pdf, doc, docx, Max. file size: 64 MB. DECLARATIONDeclaration I agree to the below declarationI/we declare to the best of my/our knowledge and believe the information given is true and undertake to render the company any assistance in dealing with this matter until it is resolved.Date DD slash MM slash YYYY EmailThis field is for validation purposes and should be left unchanged.
