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Claims | Car Fire/Theft Accident Form

   
 
  POLICY NUMBER  
  Email:  
 
  Full Name of Insured *  
  Full Postal Address *
(to which all correspondence would be sent)		  
  Occupation (Pls give full details)  
  Mobile Tel. No. *  
  Tel. No.  
  Inception Date  
  Branch  
  VEHICLE INSURED PARTICULARS  
  Make of each vehicle *  
  Registration no. *  
  CC  
  Year of manufacture  
  Engine Number  
  Chasis Number  
  Mileage Covered  
  Purpose being used  
  If commercial, type of use    
  Own Goods  
  Goods only  
  General Cartage  
Taxi/Bus  
If Taxi/Bus How many passengers  
DRIVER AT THE TIME OF ACCIDENT
Name   Age
Address      
Is Driving License in force?   If yes, which category
Driving Licence No.   Has it been endorsed?
Date of Issue   Date of Expiry
Place of Issue      
Is it a Learners' Permit?   If so, Number
Period      
Relation of Driver to Insured   If Paid Driver, for how long employed
Does Driver own a vehicle?      
If so, Name and Address of Insurer      
 
PARTICULARS OF THEFT/FIRE INCIDENT
Who discovered the loss?  
Date   Time
Exact Location of Accident      
Road Condition   Weather Condition
Speed of your Vehicle   Condition of brakes
If object collided with was moving, what direction was it going  
Address of Police Station Accident was reported  
No. of Person in (i) Insured Vehicle   The Other Vehicle
 
Who do you suspect for the loss?
When did you last service the vehicle?
By whom at where?
 
FULL STATEMENT OF THEFT/FIRE INCIDENT  
WITNESS   OCCUPANTS OF YOUR VEHICLE
Name   Name
Address   Address
Name (2)   Name (2)
Address (2)   Address (2)
 
DAMAGE TO INSURED VEHICLE  
Full details of Damaged Parts
Present Location of Vehicle
Rough Estimate of Repairs
Repairer's Name and Address
Inventory of Damaged Parts
 
THIRD PARTIES INVOLVED IN THE ACCIDENT  
Name
Address
Type of property/Injury
If Vehicle, Make
Registration No
Year of Make
Present location of Vehicle
Is Owner Insured
If Yes; Policy No.
Name and Address of Insurer
   
 
     
DECLARATION - I/We declare the foregoing particulars to be true and I/We authorize CUSTODIAN AND ALLIED INSURANCE (CAI) and/or their Legal representatives to deal with all matters arising from this accident at their discretion and if they deem it expedient to admit liability and/or negligence on the part of myself/our servants or Agents

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