Motor Accident Claim

Type of Policy

PersonalCommercialAgri

Policy Number

Insured Details

First

Last

Occupation

Address

Street Address

Address Line 2

City

Province

Postal Code

Contact Details

Contact Method

--Please choose an option--Cell numberTel no. (Work)Tel no. (Alternative)

Cell Number

Work Number

Alternative Number

Email Address

Vehicle Details

Vehicle Make

Vehicle Model

Year of Manufacture

VIN Number

Registration Number

Loss or Damage Occurrence

Date and Time of Loss / Damage Occurred

When was the Loss / Damage Discovered

Loss or Damage Place

Place where Loss / Damage occurred

Were premises Occupied?

YesNo

Purpose of Occupation of premises

Cause of Loss or Damage

Description of Incident

Loss / Damage occurred by Third Party?

YesNo

Previous Loss or Damage

Have you previously suffered a Loss / Damage?

YesNo

Type of Loss

Own DamageTheft / DamageThird PartyMalicious Damage

Other Interest

Does any other party have an interest in the insured property, e.g., Credit agreement?

YesNo

Value

Estimated total value of all property insured under the policy

Statement of Property lost, stolen or damaged

Please select the amount of items you want to claim for

Uploads

Damage Report

Replacement / Repair Quotation

Photos of Damages 1

Photos of Damages 2

Proof of ownership (in the event of theft)

Claim Form Completed By

Completed By

Broker / AdminClient

Declaration

Capacity

Signed Date

Signature