MOTOR ACCIDENT CLAIM FORM - Colfire

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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). Page 2 of 4
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: Page 3 of 4
Page 1: Head Office: Corner Duke & Abercrom

MOTOR ACCIDENT CLAIM FORM - Colfire

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