Claim Form

Policy No.

Claim No.

Motor Claim Form

The company does not admit liability by issuance of this form.

Claimant Details

Insured / Claimant Name:

Contact

Address

Driver Details

Name:

Age

License No.

Place of Issue

License Expiry

Vehicle Details

Vehicle Type

Vehicle No.

Vehicle Model

Vehicle Location

Accident Particulars

Date and Time of Accident

Place of Accident:

Declaration:

I agree to provide additional information to the company, if required. I solemnly declare that to the best of my knowledge and belief the foregoing particulars are true and correct in every respect and authorize you lodge a claim on my behalf against the third party (if any)