MOTOR ACCIDENT REPORT FORM

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1 MOTOR ACCIDENT REPORT FORM NOTE: THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM. ANY COMMUNICATION RECEIVED ABOUT ACCIDENT MUST BE SENT TO THE COMPANY AT ONCE. PLEASE DO NOT ADMIT LIABILITY FOR THE ACCIDENT UNTIL YOU HAVE CONSULTED THE COMPANY. REPORT ANY POLICE ACTION AGAINST YOU OR YOUR DRIVER TO THE COMPANY IMMEDIATELY. 1. NAME: POLICY NO: 2. ADDRESS: 3. BUSINESS OR OCCUPATION: 4. TELEPHONE NO:. 5. MOTOR VEHICLE:- (d) MAKE: CUBIC CAPACITY OF ENGINE: REGISTRATION NO: FOR WHAT PURPOSE WAS THE VEHICLE BEING USED AT THE TIME OF THE ACCIDENT? (f) IF BEING USED BY SOMEONE OTHER THAN THE INSRUED, HAD THE USER OBTAINED THE INSURED S CONSENT? WERE GOODS OR SAMPLES BEING CARRIED? 6. GIVE FULL DETAILS OF THE PERSON DRIVING OR IF NOT DRIVING, HAD CHARGE OF YOUR MOTOR VEHICLE AT THE TIME OF THE ACCIDENT:- (d) (f) (g) NAME: ADDRESS: DRIVING LICENCE NUMBER: DATE OF FIRST ISSUE: DATE PASSED DRIVING TEST: IS HE/SHE YOUR PERMANENT DRIVER? HOW LONG HAS HE/SHE BEEN IN YOUR SERVICE?

2 (h) HAS HE/SHE EVER BEEN REFUSED ANY MOTOR VEHICLE INSURANCE? i. CONVICTED OF ANY MOTORING OFFENCE? ii. IF SO, PLEASE GIVE DETAILS: IF A RELATIVE OR FRIEND OF YOURS WAS DRIVING, DOES HE/SHE OWN A VEHICLE? (j) IF SO, PLEASE GIVE DETAILS OF THE INSURANCE: 7. PLEASE GIVE THE FOLLOWING DETAILS ABOUT THE ACCIDENT:- WHEN DID IT HAPPEN? TIME: DATE: WHERE DID IT HAPPEN? IF IT HAPPENED AFTER LIGHTING-UP TIME, WHICH LAMPS ON YOUR VEHICLE WERE LIT? (d) AT WHAT SPEED WAS YOUR VEHICLE TRAVELLING KM/HR (f) WAS THE HORN SOUNDED? IF YOUR VEHICLE WAS ON THE NEAR SIDE OF THE ROAD, HOW FAR FROM THE KERB WAS IT? (g) (h) IF IT WAS NOT ON THE NEAR SIDE, WHERE WAS IT? DO YOU THINK THAT: (iii) YOU OR YOUR DRIVER WAS TO BLAME? SOME OTHER PERSON WAS TO BLAME? IF SO, PLEASE GIVE THE NAME, ADDRESS AND OCCUPATION OF THAT PERSON:-

3 SKETCHES 8. PLEASE DRAW SKETCHES BELOW SHOWING:- (iii) (iv) (v) THE DIRECTION OF THE VEHICLES WITH ARROWS THE POINT OF THE IMPACT WITH A CROSS ANY MARKS ON THE ROAD ANY MEASUREMENTS ANY TRAFFIC SIGNS BEFORE THE ACCIDENT AFTER THE ACCIDENT

4 9. PLEASE GIVE DESCRIPTION OF HOW THE ACCIDENT HAPPENED: 10. WHAT IS THE DAMAGE TO YOUR VEHICLE? (C) WHERE CAN THE VEHICLE BE SEEN? NAME AND ADDRESS OF NEAREST REPAIRER(S) IF YOU HAVE OBTAINED AN ESTIMATE FOR THE COST OF REPAIRS, PLEASE ATTACH IT.

5 THIRD PARTIES INVOLVED IN ACCIDENT 11. NAME AND ADDRESSES OF PERSONS INJURED AND THE EXTEND OF THEIR INJURIES INJURED PERSONS IN YOUR VEHICLE:- INJURED PERSONS IN THE OTHER VEHICLES: INJURED PEDESTRIANS 12. STATE DETAILS OF OTHER VEHICLE INVOLVED: INJURED PERSONS IN THE OTHER VEHICLES:- REGISTRATION NO: MAKE: MODEL: STATE NAME AND ADDRESS OF THE DRIVER OF THIS VEHICLE:- STATE NAME AND ADDRESS OF THE OWNER OF THIS VEHICLE:- (d) STATE NAME AND ADDRESS OF THE INSURER OF THIS VEHICLE AND POLICY NO:- DETAILS OF DAMAGE TO THIS VEHICLE:-

6 (f) HAS ANY CLAIM BEEN MADE UPON YOU? YES/NO. IF SO, STATE PARTICULARS BELOW AND NOTE THAT ANY LETTER OF COMMUNICATION RECEIVED BY YOU MUST BE FORWARDED IMMEDIATELY UNANSWERED, TO THIS COMPANY. 13. DID THE POLICE:- WITNESS THE ACCIDENT? YES/NO TAKE ANY EVIDENCE OR PARTICULAR? YES/NO DID YOU OR YOUR DRIVER GIVE A SIGNED STATEMENT TO THE POLICE? 14. WITNESSES: PASSENGERS IN YOUR VEHICLE:- (1) (2) (3) INDEPENDENT WITNESSES:- (1) (2) (3) 15. PLEASE PROVIDE NAME OF POLICE OFFICER WHO IS INVESTIGATING THE ACCIDENT:- POLICE STATION: 16. DO YOU HOLD MORE THAN ONE POLICY INDMENIFYING YOU IN RESPECT OF THE ACCIDENT: YES/NO I/We declare that the above statement is true in all respects to the best of my/our knowledge and belief, and I/we hereby leave in the hands of the Company in accordance with the conditions of the policy the conduct of all claims and litigation arising out of this accident and to which the policy applies, to deal with, to prosecute and/or settle as they think fit without further references to me/us, and I/We undertake to give all such information and assistance as the Company may require. DRIVER S SIGNATURE: INSURE S SIGNATURE: DATE:

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