Scribd
Upload
37 views4 pages

Motor-Insurance-Claim-Form

Thanks

Uploaded by

Moses Utumbe namandwa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
37 views4 pages

Motor-Insurance-Claim-Form

Thanks

Uploaded by

Moses Utumbe namandwa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 4

CO-OPERATIVES GENERAL INSURANCE LTD.

MOTOR INSURANCE
CLAIM FORM

Agency/Broker:

CUSTOMER INFORMATION

Surname: Other Names:

Postal Address: Code: Town:

Policy Number: Telephone Number:

Mobile Number: Email Address:

PIN No: ID/Passport No:

Occupation:

VEHICLE DETAILS

Registration: Year: Make: Model:

Financier’s Name (if applicable):

DRIVER DETAILS

Who was driving at the time of the accident?: Surname:

Other Names: Occupation:

Address, Telephone Number, Mobile Number (if different from above):

Date of Birth: DD / MM / YYYY ID/Passport No:

Relationship to insured: PIN No:

Driver’s License No: Date Issued: Gender: Male Female

How long have you been driving?

Had you consumed any intoxicating liquor or taken any medication or other drugs within 6 hours prior to the
accident? YES NO If yes to any of the above, please give details:

If you are not insured, do you have a vehicle of your own? YES NO If yes, who is the insurer?

Have you ever been convicted in the last 5 years of any offence in connection with any motor vehicle, or is any
prosecution or Police enquiry pending? YES NO If yes to any of the above, please give details:
ACCIDENT DETAILS

What was the Date of the Accident?: Time: AM/PM

Where did the Accident occur? Town: Road:

What was your Speed at the time of the Accident in Mph/Kmh?: Were your headlights on?:

What was the Weather Condition at the time of the Accident?:

What warning was given immediatley prior to the Accident?:

Where is the Vehicle now?:

Name of the Repairer/Garage (see list from CIC panel of garage):

Contacts:

Details of Towing Agency:

Did the Police witness or attend the Scene of the Accident? If yes, please write the name of the

Police Officer: Force Number:

Name of Police Station: O.B. Number:

How many Occupants were in your Vehicle?:

Was the Driver or any Passenger(s) in your Vehicle injured as a result of this Accident? If yes to any of
the above, please give details:

Name Nature and Extent of Injuries Relationship to the Insured

Please illustrate damage to your vehicle by indicating an X on the diagram below:


Give a brief statement describing the extent of damage:

Sketch plan of Scene of Accident:

DRIVER’S STATEMENT:

PLEASE WRITE AND SIGN A COMPREHENSIVE STATEMENT DETAILING


CIRCUMSTANCES SURROUNDING REGARDING THE ACCIDENT ON A SEPARATE SHEET OF PAPER

Did you admit liability?: Signature:

INSURED’S STATEMENT:

PLEASE WRITE AND SIGN A COMPREHENSIVE STATEMENT


REGARDING THE ACCIDENT ON A SEPARATE SHEET OF PAPER

Have you ever made any claim or been in an accident in connection with a vehicle in the last 5 years?:
If yes, please provide full details:

Was the vehicle being driven without your authority or permission?


If yes, please provide full details:

PERSONAL INJURY TO THIRD PARTIES (if applicable)

Was anyone else injured as a result of this accident? (Pedestrian or Passenger in the other vehicle):

If yes, please avail the following details: Name, address, hospital attended, nature and extent of injuries:
THIRD PARTY PROPERTY DAMAGE DETAILS (if applicable)

Was there any third party property damage? Motor Vehicle Other properties
If yes, please avail the details (as applicable):

Name of Owner:

Name of Driver:

Address:

Registration No.: Make:

Extent of the damage:

Third party’s insurer: Policy number:

Did the other driver admit liability for the accident?

WITNESSES

Please provide names and contact details of all witnesses to this accident

Name: Contacts:

Name: Contacts:

USE OF THE MOTOR VEHICLE

For what purpose was the vehicle being used at the time of the accident?

Give a description of goods being carried (if applicable):

Name of owner of goods carried:

DECLARATION
I/We hereby declare that the whole of the statements made by me/us in this claim form are in every respect
true, and I/We agree that if I/We have made any false or untrue statement(s), or there be any suppression or
concealment of any material fact, my/our right to recover under the policy shall be absolutely forfeited.

Date: DD / MM / YYYY : Rubber Stamp / Seal

Insured’s Signature

FOR OFFICIAL USE ONLY

The following supporting documents are required:


• Original Police Abstract
• Copy of Driver’s Licence
• Evidence of Excess Payable (where applicable)

CO-OPERATIVES GENERAL INSURANCE LTD


Jash Building, Plot 4/387, Colby Road P.O. Box 882 Lilongwe, Malawi
+265(1) 751 026, +265(1) 751 017 [email protected] www.cic.co.ke
CICinsurance CICinsurance CICinsurance
KENYA • SOUTH SUDAN • UGANDA • MALAWI
GENERAL • LIFE • HEALTH • ASSET

You might also like