Motor Claim Form Policy Details Name of Policyholder Address of Policyholder Tel. # Occupation Date of Birth Policy No. Type of Policy Policy Period Annual Premum Accident Details Date of Accident Time of Accident Where did the accident take place? Was the Accident reported to the Police? Name of Policeman Name of the driver at the time of the accident Who is your opinion is at fault? Was the driver warned of intended Prosecution by the police officer? Was the driver under the influence of alcohol or drugs? Did the driver of the other vehicle appear to be under the influence of alcohol or drugs? What was the condition of the road? Road Surface What was the weather and visibility like? Speed before the Accident Purpose for which vehicle was being used at the time of the Accident Direction of Travel Which side of the road? Was horn sounded? Were lights on/off/dim/bright? Details of Damage Did a wrecker remove the vehicle? Can the vehicle be driven? Where can the vehicle be inspected? How many passengers were in your vehicle Was anyone injured in the accident? Were there any witnesses? Vehicle Details Make & Model Year Type Reg. # Colour Chassis No. Type Condition Vehicle Value Mortgagee Driver Details Name of Driver Date of Birth Address of Driver Occupation Class of Licence Driving Experience Drivers Licence No. Date of issue Date of Expiry Was Driver permitted to drive? Any previous Accidents? Is the Driver related to the Insured? If so, how? Third Party Details (Vehicle) Name of Third Party Contact No. Insurer Vehicle Make & Model Type Reg. # Details of damage to Vehicle Name of Third Party Contact No. Insurer Vehicle Make & Model Type Reg. # Details of damage to Vehicle Third Party Details (Driver/Passengers/Pedestrians) Name of Injured Person Nature of injury Occupation Was person hospitalized after accident Name of Injured Person Nature of injury Occupation Was person hospitalized after accident Name of Injured Person Nature of injury Occupation Was person hospitalized after accident Sketch diagram of Accident Statement The driver should state as fully and clearly as possible, all details pertaining to the accident(before and after) I/we here by declare that the above information is true and accurate to the best of my/our knowledge and belief. I/we also understand and agree that any false statement or misrepresentation of facts stated by me/us will result in the refusal of PIL to entertain any claim under the policy and will ultimately allow PIL to cancel the policy with immediate effect. Signature of Insured Date Signature of Driver Date For office use only Claim No. Deductible Retention Date Received Date Settled: Agency: Full Premium Received: Salvage Amt: Claim Handler: Remarks:
