MOTOR ACCIDENT CLAIM FORM - Colfire

Head Office: Corner Duke & Abercromby Street, Port of Spain, Trinidad W.I.
Telephone: (868) 623-2201-3/5 Fascimile: (868) 623-0925 E-mail: info@colfire.com Website: http://www.colfire.com
MOTOR ACCIDENT CLAIM FORM
It is essential that all questions are fully answered whether of not a Claim is being made against the Policy. Completing all questions will expedite the processing/settlement of the claim.
1. POLICYHOLDER'S INFORMATION
Title: First Name: Middle Initial: Surname:
Address:
City:
Telephone No(s).: Home: Work:
Mobile:
E-mail Address:
Occupation or Trade:
Policy No:
Are you V.A.T. registered?
Yes
No
If Yes, State your V.A.T. Registration Number:
Employer's Name: Title: First Name: Surname:
Employer's Address:
City:
Is the vehicle mortgaged? Yes No If Yes, with which company
2.
PARTICULARS OF INSURED'S MOTOR VEHICLE
Registration No: Make and Model of Vehicle: Colour of Vehicle:
For what purpose was the Vehicle being used?
Are there any other Policies of Insurance in force indemnifying you in respect of this accident? Yes No
If Yes, give particulars / details
3. PARTICULARS OF DRIVER
Title:
First Name:
Middle Initial:
Surname:
Address:
City:
Telephone No(s).:
Home:
Work:
Mobile:
E-mail Address:
Employer's Name:
Employer's Address:
City:
Date of Birth: (YYYY-MM-DD) Age: Years Driver's Licence No:
Date First Issued: (YYYY-MM-DD) Renewal / Payment Date:
(YYYY-MM-DD)
Did the Driver hold a current Driving Licence at the time of the Accident?
Yes
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No

PARTICULARS OF DRIVER Continued...
Did the Driver have any previous accidents?
Yes
No
If Yes, give please give full details:
Has the Driver ever been convicted of any offence in connection with the driving of a Motor Vehicle within the past four years?
Yes
No
If Yes, give please give full details:
Relationship of driver to Insured:
Was the Vehicle being driven with the Insured's consent and knowledge?
Yes
No
Is the Driver your paid employee?
Yes
No
If Yes, how long has he / she been employed?
Nature of his/her employment:
Does the Driver own a vehicle?
Yes
No
Policy No.:
If Yes, with which Insurance Company is the vehicle insured
4.
DETAILS OF ACCIDENT OR LOSS
Date of Accident or Loss:
(YYYY-MM-DD)
Time:
(HH:MM)
Location (street name etc.):
Was your vehicle on the correct side?
Yes
No
On the major road?
Yes
No
Road Conditions
WET DRY OTHER
Please State:
Weather Conditions:
SUNNY RAINY OTHER
Please State:
Where were you coming from?
What lights on your vehicle were in use? What was your travelling speed? kmph
To which Police Station was the Accident / Loss Reported?
Officer's Name:
Title:
First Name:
Surname:
Officer's Badge No:
State the circumstances causing the Accident / Loss (include name and registration no. of other vehicles involved and whether horn was sounded or other warning
given).
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DETAILS OF ACCIDENT OR LOSS Continued...
In your opinion, who was at fault?
Did such person admit liability?
Yes
No
5.
WITNESSES OF ACCIDENT
State Names, Addresses and Ages of the occupants in the Insured Vehicle:
State Names and Addresses of any Independent Witnesses
Did Witnesses or Drivers make any statements as to fault at the time?
Yes
No
6.
PARTICULARS OF DAMAGE TO INSURED'S MOTOR VEHICLE
State details of damage to Insured's vehicle:
Where is it desired to have repairs carried out?
Estimated Cost of Repairs:
Address where damaged vehicle can be seen:
7.
PERSONS INJURED
(Injured Person 1)
(Injured Person 2)
Name:
Name:
Address:
Address:
Telephone No(s).:
Home:
Telephone No(s).:
Home:
Work:
Mobile:
Work:
Mobile:
Date of Birth:
(YYYY-MM-DD)
Date of Birth:
(YYYY-MM-DD)
Details of Injury:
Details of Injury:
8. THIRD PARTY PROPERTY DAMAGE(1)
THIRD PARTY PROPERTY DAMAGE(2)
Owner's Name:
Owner's Name:
Address:
Address:
Driver's Name:
Driver's Name:
Address:
Address:
Telephone No(s).:
Home:
Telephone No(s).:
Home:
Work:
Mobile:
Work:
Mobile:
Registration No.:
Registration No.:
Make & Model of Vehicle:
Make & Model of Vehicle:
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THIRD PARTY PROPERTY DAMAGE (1) Continued...
Insurer:
THIRD PARTY PROPERTY DAMAGE (2) Continued...
Insurer:
Policy No.:
Policy No.:
Details of Damage:
Details of Damage:
Has any intimation of Claim been made upon you, either verbally or in writing? Yes No
Note:
Any written communication should not be answered and forwarded immediately to COLFIRE. If verbal notice has been received, particulars should
be given above.
9.
ADDITIONAL INFORMATION:
I
the undersigned do hereby authorize COLFIRE to disclose any information in respect of my Claims history to any Investigator, Adjuster, Insurance Company,
Regulatory Body or other Authority, and hereby release COLFIRE from any claims and liabilities of any kind in respect of such disclosure except claims and liabilities
that may arise under this document.
I certify that the foregoing statement is a true account to the best of my knowledge and belief.
Date:
(YYYY-MM-DD)
Insured's Signature
Date:
(YYYY-MM-DD)
Insured's Signature
Any further information which can be given should accompany these particulars.
Please use a blank sheet of paper to provide additional information where space provided is insufficient.
Be sure to attach to the Claim Form.
Download the form and fill it out on your computer.
When you are finished, save the form and submit via email to info@colfire.com
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