MOTOR ACCIDENT CLAIM FORM
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1 MOTOR ACCIDENT CLAIM FORM INSURED Insurer Policy No. Occupation VEHICLE Make Model Odometer Reading Value Tare Gross Vehicle Mass Registration No Date of purchase Purchase price If vehicle is subject to a Hire Purchase, Credit or Leasing Agreement, state name and address of Finance Company: DAMAGE Damage to own vehicle Estimate for repairs or attach quote Repairers name address and telephone number Where can your damaged vehicle be inspected? DRIVER Full ID Number Occupation Drivers Licence no Drivers Licence date CPT PHONE FAX ADDRESS Block A & B Edison Square Cnr. Edison Way & Century Avenue Century City POSTAL PO Box 84 Century City 7446 DBN PHONE FAX ADDRESS Viewz 11 The Boulevard, Westway Office Park, Westville 3630 POSTAL PO Box 2725, Westway 3630 JHB PHONE FAX ADDRESS MUA House, 26 Sturdee Avenue, Rosebank, Johannesburg 2196 POSTAL PO Box , Bryanston 2021 MUA Insurance Acceptances (Pty) Ltd is an authorised Financial Services Provider (FSP No.: 37947) underwriting on behalf of Compass Insurance Company Limited. An authorised Financial Services Provider (FSP No.: 12148) REGISTRATION NUMBER 2008/011925/07 DIRECTORS R A Gainsford (Chairman) C Y Fourie (Managing Director) L Keel (Swiss) T Muranda V J Hayter info@mua.co.za WEB
2 DRIVER Drivers licence code Drivers licence learners or full? Drivers licence place: State fully the purpose for which the vehicle was being used Was the vehicle being used with your permission? Was the driver in your employ? Has the driver any motor insurance? If YES, please state Policy No Insurer Details of any convictions for motoring offences Has licence been endorsed? Does the driver have any physical defects? Details of previous accidents Advanced Driving Course? (If yes please attach certificate) PASSENGERS (insured Vehicle) Details of Passengers in the Insured vehicle Injury For what reason were they being transported? Are they employees? OTHER PARTY DETAILS Damage to other vehicle of owner & driver of owner & driver 2
3 OTHER PARTY DETAILS of owner & driver of owner & driver of owner & driver of owner & driver of owner & driver of owner & driver Damage to property other than vehicles of owner of owner of owner of owner of owner of owner Personal Injuries (other than in Insured vehicles) of hospital (if applicable) of hospital (if applicable) of hospital (if applicable) of hospital (if applicable) 3
4 WITNESS THEFT Was vehicle locked? Who has the keys? Police Station Engine No Police Case No Chassis No Colour Details of Accessories stolen ACCIDENT DETAILS Speed before accident Weather conditions Road Surface Which vehicle lights were on? Speed on impact Visibility Width of road Street lighting Was any warning, e.g. hooting, indication etc. given by you? Police Case No. Was the driver tested for alcohol or drugs? Police Station Result of test Description of accident 4
5 ACCIDENT DETAILS Sketch of Accident (if necessary, please use a separate page). Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety or warning signs in the vicinity of the scene of accident. DECLARATION We hereby declare the foregoing particulars to be true in every respect Signature of driver Date Signature of insured Date Capacity NB. It is important that you notify Insurers immediately you become aware of any impending prosecution, inquest or demand BANK DETAILS Bank Branch Code Account Holder Account No 5
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