Vehicle Accident Claim Form

Policy number:

Surname or Company Name

Initials

Identity Number

Email Address

Phone number - Home

Phone number - Work

Cellphone number

Date of the accident

Time of the accident

At what address did the accident occur?

City

Police/Traffic Department where the accident was reported

Date reported and to whom (name)

Police/Traffic Department reference number

The Vehicle Make

Short Description of the accident *

For what purpose was the vehicle being used? *

The driver of the vehicle at time of accident is the same person as the policy holder

Driver's Surname

Driver's Initials

Driver's Title *

Relationship with insured (eg. self, child, friend, employee)

Driver's ID Number

Driver's licence code

Date issued

Driving on Learner's Licence?

Had the driver consumed alcohol prior to driving?

Was a blood sample taken after the accident?

If a blood sample was taken what was the result?

Make of the vehicle

Year of Manufacture

Registration of the vehicle

Is the vehicle insured under any other policy?

Name and address of the registered owner

Surname

Initials

Address

City

Province

Postal code

Estimated cost of repairs

Do you have a quote for the repairs to the vehicle?

If yes, by whom?

Phone number

Address where the vehicle may be seen

City

Have any passengers in your vehicle sustained injuries?

Make of other vehicle

Registration number of other vehicle

Eye witness?

Eye witness Surname

Eye witness Initials

Eye witness Phone Number Home

Eye witness Phone Number Work

Eye witness Cellphone Number

Name and Surname:

Identity number:

Vehicle registration number:

Type of vehicle:

Telephone / Cellphone number:

Other details:

*

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