NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel , Fax Motor Accident Claim forms

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1 NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel , Fax Motor Accident Claim forms Please complete this form in Block Capitals. Answer all questions fully and accurately to avoid unnecessary delays in settling this claims and return same with the relevant documents not later than 30 days from the date of Accident. Issue of the form is not an admission of liability by National Insurance Trust Fund Policy No - Claim No - 1. and Address of. Insured owner... Phone No... I.D. No: of driver at the I.D. No:... Time of Accident DL no and date of issue:... Date of Expiry (if applicable)... Is the driver a holder of a Certificate of competence to Yes No drive this Vehicle Are there any driving convictions or any charges pending in a court of law 3. Vehicle Information Please submit original DL for scrutiny and Address of Legal owner Purpose of use Registration No. Make & Model.. Chassis No Year of Make. Private Hiring Rent a Car Trade Is the Vehicle under Finance, Hire Purchase Yes No or Loan Agreement If yes, of the Institution... Agreement No

2 Is there any other insurance in force on the Vehicle Yes No or on the goods carried If Yes, give details Passengers No of Passengers carried in addition to driver. Were they carried for Fee / Reward Yes No 5. Goods carried if goods carried, for Hire Contract Owner Description of goods Value, Weight & Quantity Carried Value of Damaged Goods and Address of owner of Goods Place of Loading.. (continue in a Separate Sheet, if space is required) 6. Accident / Loss and Theft Day Month Year Time of Road and closest km/ mile Post where Accident / Loss/ Theft Occurred...

3 Is theft of Vehicle Parts Details If the vehicle is recovered before or after any settlement advice National Insurance Trust Fund immediately. When found, and the Police Station informed. 7. Accident Information Date & time of accident.. Place of accident.. Weather Visibility Speed at time of accident Accident /Loss/Theft reported to Police - Yes No Date and Time Reported... Police Station where reported... Did Police inquire or visit scene of Accident - Yes No Brief description of accident 8. Repairer and Address... Telephone Number. Where can Vehicle be Inspected Owner repair Yes No At garage At Work Place At Residence

4 9. Third Party Make and registration and Address of & Address of number of Vehicle/ Owner of Driver description of Property and Address of the Insurance Co. & Policy No -... Extent of Damages to Vehicle / Property: Declaration I/ WE declare that all particular given are true and correct to the best of my/ our knowledge and no material information has been with held connected to the Claim. All co-operation required in relation to this claims will be provided. I/We agree if any false or fraudulent claims made by me/ us or any one acting on my/ /our behalf, then the claim shall result in repudiation of the Claim. I/We also declare that the Loss or damage sustained to my/ our vehicle is solely as a result of this accident / event described herein. Insured Signature Date: Important Do not agree or compromise with any parties involved in this accident. Do not admit liability to any third parties. Any Claim/ Letter of demand received should be sent to us immediately. No part of the Vehicle should be dismantled without prior approval from us. At the time of producing the vehicle for the first inspection the following documents are required. 1. An estimate in duplicate for the repair. 2. The driving license of the driver who was driving the vehicle at time of accident. 3. Certified copy of the 1 st statement made to the Police. 4. Duly completed Claim form. 5. A copy of the Vehicle Registration. If documents are not attached (except estimate) at the time of the inspection, you are required to do so not later than 30days of the date of Accident.

5 LATTEROF INDEMNITY. I...of being the owner of the vehicle bearing Registration No... and being the holder of insurance Policy No..issued by the National Insurance Trust Fund (Motor Department),herby confirm that the aforementioned vehicle met with an accident on.. At..and I honestly and firmly believe myself if to be entitle to be indemnified by the National Insurance Trust Fund (Motor Department ),in terms of the aforementioned Policy of Insurance. In consideration of the National Insurance Trust Fund (Motor Department), dispensing with some or all of the usual investigation with a view to expedition the payments of aforementioned claims. I, the said Hereby unconditionally undertake to reimburse the National Insurance Trust Fund (Motor Department), all sums of money paid by the National Insurance Trust Fund (Motor Department), in the event of the National Insurance Trust Fund (Motor Department), alleging that the sum paid or any part thereof was not due to me on account of the accident not having taken place at all or in the manner alleged by us, on account if the violation of any policy condition or on account of any other matter or cause whatsoever. Signed at this..day of 200. (Signature) (Over Rs.10/- stamps) 1. Witness Signature Address 2. Witness Signature Address

6 LETTER OF SUBROGATION. To: National Insurance Trust Fund (Motor Department) 70, D.R.Wijewardena Mawatha, Colombo 10. Claim No. Policy No..... In consideration of your settling by a payment of a sum of Rupees (Rs...) a Claim under Policy No..effected with you, on the property mentioned in the schedule hereon, I/we hereby assign, transfer and abandon to you all right title and interest in and to the said property and the proceeds thereof, and all that can or may in any way be made saved or realized from the damage or loss reported to have occurred to the said property or any other person in respect of damage howsoever caused and all rights against any person or person responsible for the loss and to grant you full power to take and use all awful ways and means in my/our or your own name otherwise at your risk and expense to save and realise the said property or its proceeds and hereby agree to subrogate to you the same rights as I/we have in consequence of or arising from the said loss or damage. And I/we undertake and agree to make and execute at your expense, all such further deeds, assignments and documents and render such assistance as you may reasonably require for the purpose of carrying out this agreement. SHEDULE Marks, Nos.and Description of Property:..... On this..day of Rs.10/- Stamps Signature Address :. :.

7 DISCHARGE VOUCHER. Claim No : Date:. Vehicle No :. We/I the undersigned Do hereby acknowledge receipt from National Insurance Trust Fund (Motor Department), 70, D.R.Wijewardena Mawatha, Colombo 10, a sum of Rs.. (Rs.) in full and final settlement of claims made upon them under policy No.. For loss and / or damage, which occurred on It is hereby agreed that we/i have no further claim against the said Fund, in respect of the above mentioned claim, and do hereby give a full and final discharge.. Signature Witnesses:- (1) Witness Signature Address (2)Witness Signature Address

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