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*

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.

My Account

Add Files

The company

Company

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