Claim Application

The data below will be used to complete a claim form for your respective insurance company
Policy Holder(s) Driver's Permit Copy
Driver of Vehicle - Driver's Permit Copy (if different)
Certified Copy
Pic 1 (VIEW WITH REGISTRATION NUMBER) FULL FRONT / REAR / SIDE AS NEEDED
Pic 2 (CLOSE UP ON DAMAGE/CRACK)
Pic 3 (VIN / CHASSIS NUMBER FROM BODY OF VEHICLE)
Certificate of Insurance

Name*

First Last

Address

Street Address Address Line 2 City Country

Phone*

Email*

Occupation / Trade

Policy Number*

Employer's Name*

Employer's Address*

Street Address Address Line 2 City Country

Is the vehicle mortgaged?*

Yes

Enter mortgage company name*

Registration Number*

Make and Model of Vehicle*

Color of Vehicle*

For what purpose was this vehicle being used?*

Are there any other Policies of Insurance in force indemnifying you in respect of this accident?

Yes

If Yes, give particulars / details*

Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City Country

Employer Name*

Employer Address*

Date of birth*

Age (in years)*

Driver's License Number*

Date of License Issuance*

License Renewal/payment Date*

Did the Driver hold a current Driving Licence at the time of the Accident?*

Yes

Did the Driver have any previous accidents?*

Yes

Details of previous accidents*

Relationship of driver to insured*

Was the Vehicle being driven with the Insured's consent and knowledge?*

Yes

Is the Driver your paid employee?*

Yes

how long has he / she been employed?*

Nature of his/her employment:*

Date of accident / loss*

Time*

Location (street name etc.):*

What lights on your vehicle were in use?*

What was your travelling speed? (kmph)*

State the circumstances causing the Accident / Loss and provide any additional information on damage:*

Add Files

Pic 1 (view with registration number)

Full Front/ Rear/ Side as needed

Max. file size: 256 MB.

Pic 2

Close up on damage / crack

Max. file size: 256 MB.

Pic 3

VIN / Chasis number from body of vehicle

Max. file size: 256 MB.

Pic 4

DP of Driver

Max. file size: 256 MB.

Pic 5

DP of Insured (if different)

Max. file size: 256 MB.

Pic 6

Certified Copy

Max. file size: 256 MB.

Pic 7

Certificate of Insurance

Max. file size: 256 MB.

I certify that the foregoing statement is a true account to the best of my knowledge and belief.

I do hereby authorize ClearView to disclose any information in respect of my Claims history to any Investigator, Adjuster, Insurance Company,
Regulatory Body or other Authority, and hereby release ClearView from any claims and liabilities of any kind in respect of such disclosure except claims and liabilities
that may arise under this document.

My Account

Add Files

The company

Company

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