SECTION 1 - PLEASE COMPLETE SECTION 1 IN ALL CASES
INSURED
Surname/Company Name,

First Name:	

Address,	

Telephone No:	Business/Occupation:	

Policy/Certificate No:

DD/MM/YYY

              :        AM/PM

DATE & TIME OF INCIDENT:
Please state the Police reference number

and the address of the Police Station:	

VEHICLE
Make & Model:	Registration No:	

Chassis/Frame No:	Year of Mfg_	

Value:	Where is the vehicle kept overnight?	

For what purpose was the vehicle being used at the time of accident?	
Is the vehicle subject to (a) Hire Purchase (b) Lease Agreement?   (a) (b)
If you have ticked (a) or (b), please state the name, address and agreement number  
DRIVER Last in Charge of vehicle (this section must be completed. even if the driver is the policy holder, and the vehicle was parked or stolen)
Name: 	Age 			                     Tel No:
Address: 	Occupation:

Type of License held:	License No:

When issued:	Expiry:

SECTION 2-PLEASE COMPLETE SECTION IN ALL CASES

At what speed was your vehicle travelling when the accident happened?	Miles/ Kms
What were the weather conditions (e.g. dry, raining)?
Do you think your driver was responsible for the accident?  (YES)			(NO)
If 'No', who was? (name and address)
SECTION 3 - PLEASE COMPLETE SECTION 3 IN ALL CASES
THEFT DETAILS
Where did it happen, i.e. location?
What protections were fitted to the vehicle?	
Were they in use where the theft occurred?
SECTION 4 - PLEASE COMPLETE SECTION 4 IN ALL CASES
DAMAGE TO THE INSURED VEHICLE
Please describe in detail the damage to your vehicle
Is the vehicle immobile?  (YES) (NO)	Can the vehicle be inspected? (YES) (NO)  If Yes, where is it located?
	                                                       If No, Why?
DETAILS TO OTHER VEHICLES INVOLVED
Name, address & telephone no.
of the owner	Name, address of driver if different	Vehicle make & registration no	Name, address & policy not of
insurers	Nature of damage
If none, write 'NONE')	

					
DETAILS TO OTHER PROPERTY
If there was any damage to other property other than vehicles please give details
Please give details of property damage	Name, address & telephone no. of the owner	Name, address & policy no. of others	

			

Injuries
If anyone was injured please give details
Name & address of injured party	Name of the hospital if the person was detained	Nature of injury/ies	

			

SECTION 5-PLEASE COMPLETE SECTION 5 IN ALL CASES

Briefly describe the incident (with diagrams if relevant)

	

	

Please draw sketches below showing (i) the direction of the vehicles, with arrows, (ii) the point of impact with a cross, (iii) any marks on the road, (iv) any measurements, and (v) any traffic signs

Before accident

After the accident

Please give the names, addresses & telephone nos of any witnesses below:
(1)	Passengers in your vehicle 

(2)	Others

DECLARATIONS
I/We declare that the information given in this form is true & correct to the best of my knowledge/belief. 
I authorize you to deal with this claim within the terms of my/our behalf if appropriate.

I/We understand that you may seek information from other insurers to check the answers I/We have provided. 

Driver’s Signature							Insured’s Signature 

Date								Date