Motor Accident Report Form
|
|
|
- June Fox
- 8 years ago
- Views:
Transcription
1 Motor Accident Report Form
2 Tel: Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: INSURED Motor Accident Report Form Policy. Name Home Tel.. Work Tel.. Mobile Occupation VAT Registered: Partial DRIVER Name Date of Birth Home Tel.. Work Tel.. Occupation Was driver in insureds employ at time of accident? Does driver have any physical defect, infirmity, defective vision or hearing? Has driver ever been convicted of a motoring offence, or is there any prosecution pending? Has driver been involved in any accidents and/or losses in the last 3 years? Has driver ever been declined motor insurance? Is a full U.K. Driving Licence held? Driving Licence Number. Date test passed. For what purpose was vehicle being used at time of accident? Motor Accident Claim Form. Version 7. v of 5
3 INSURED VEHICLE Make Model Purchase Price Year Reg. Date of Purchase Current Value Can you recover VAT for the vehicle? Is vehicle covered by Hire Purchase/Lease Agreement? If yes please give name, address of company concerned and Agreement Number. DAMAGE TO INSUREDS VEHICLE Describe damage Is vehicle still in use? If, where is the vehicle now? Repairers name and address. Repairers Tel.. Cost of repairs OTHER PARTIES Name and address of owner/driver. Insurers. Policy. Vehicle type / make Reg. Damage to vehicle. 2 of 5 Motor Accident Claim Form. Version 7. v 2009
4 DETAILS OF INJURED PERSONS 1) Name and address. In whose car were they travelling? Were they a: (a) Driver? (b) Passenger? (c) Pedestrian? Please describe their injuries. Were they taken to hospital? Were they wearing a seat belt / crash helmet? 2) Name and address. In whose car were they travelling? Were they a: (a) Driver? (b) Passenger? (c) Pedestrian? Please describe their injuries. Were they taken to hospital? Were they wearing a seat belt / crash helmet? WITNESSES 1) Name Was this witness known to you prior to the accident? 2) Name Was this witness known to you prior to the accident? Motor Accident Claim Form. Version 7. v of 5
5 DETAILS OF THE ACCIDENT Date Location Town Condition of road Weather conditions Time Street County Width of road Visibility Were the street lights on? Applicable speed limit. INSURED THIRD PARTY Estimated speed before accident. What signals were given? What vehicle lights were on? Did the police attend or were they informed? If yes please give name and number of attending officer. Police station address. Have you received any notice of intended prosecution? If yes please give details. Who do you think was responsible for the accident? DESCRIBE THE ACCIDENT CIRCUMSTANCES 4 of 5 Motor Accident Claim Form. Version 7. v 2009
6 SKETCH PLAN PAYMENT OF CLAIM To avoid postal delays and the risk of theft we will pay any agreed amount due to you in respect of your claim directly into your bank account. Please complete the following details about your bank account Bank Name Bank Account Number Sort Code Bank Account Name If you would however prefer to receive a cheque please tick here NOTICE Insurers pass information to the Motor Insurance Anti-Fraud and Theft Register run by the Association of British Insurers (ABI). The aim is to help us to check information provided and also prevent fraudulent claims. Under the Conditions of your Policy, you must tell us about any incident (such as an accident or Theft) which may or may not give rise to a claim. We will pass information relating to this incident to the Register. DECLARATION I/WE DECLARE THAT THE PARTICULARS ON THIS FORM ARE CORRECT TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF. I/WE UNDERSTAND THAT YOU MAY ASK FOR INFORMATION FROM OTHER INSURERS TO CHECK THE ANSWERS I/WE HAVE PROVIDED. Signature of insured Date Signature of driver Date Motor Accident Claim Form. Version 7. v of 5
7 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE W Rural Insurance Group Limited is Registered in England and Wales. Registered Registered Office: Cast House, Old Mill Business Park, Gibraltar Island Road, Leeds, West Yorkshire, LS10 1RJ Rural Insurance Group Limited is Authorised and Regulated by the Financial Services Authority.
Motor vehicle Accident report form
Motor vehicle Accident report form The issue of this form is not an admission of a claim Insurers maintain a motor insurance anti-fraud and theft register and exchange information with each other to prevent
Personal Accident & Sickness Claim Form
Personal Accident & Sickness Claim Form Tel: 01423 876000 Rural Insurance Group Limited The Lenz Hornbeam Park Harrogate HG2 8RE Fax: 01423 874127 IMPORTANT Please complete pages 1, 2 and 3 in full including
Motor Accident Claim Form
Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested
MOTOR VEHICLE ACCIDENT CLAIMS
MOTOR VEHICLE ACCIDENT GUIDANCE NOTES AND REPORT FORM MOTOR VEHICLE ACCIDENT CLAIMS GUIDANCE NOTES The following notes have been prepared to help you make your claim. We recommend that you read them carefully
MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE)
Insurance Company Limited MOTOR ACCIDENT REPORT (NOT FOR USE ON THEFT CLAIMS OR MOTOR TRADE) First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder
Motor Accident Report Form
Completing the claim form It is always important to notify your Insurer of a claim as soon as possible after an accident has occurred. Please therefore complete this form and return it to us within 14
MOTOR TRADE CLAIM FORM
Insurance Company Limited MOTOR TRADE CLAIM FORM First Response Claims Line 0845 373 1300 Fax 020 7068 7740 Email claims@tradex.com www.tradex.com Policyholder s Name Company Name Policy No. (cover note
Motor Accident Claim Form
Motor Accident Claim Form Agricultural Commercial & Private Vehicles www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested
Motor Accident Report Form
POLICYHOLDER DETAILS Policy Number: Name of Insured/Trading Title Claim Ref: Date of Birth: Email Occupation/Business Daytime Are you registered for VAT? Yes No If Yes please state VAT reg. no. PERSON
MOTOR ACCIDENT FORM. General Information. Insured. Daytime phone no. Date of Birth Occupation
MOTOR ACCIDENT FORM Please complete this form and return to Sagar Insurances, 30 Willow St, Accrington, BB5 1LU T 01254 391411 : F 01254 872720 : E claims@sagarinsurances.co.uk Please note, if anyone has
MOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Policy No.: VAT Reg. No.: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Make: Tare: Gross Vehicle Mass: Kilometers: Date Purchased: Price Paid:
PRIVATE CAR ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd PRIVATE CAR ACCIDENT REPORT FORM Link House 292-308 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0844 620 1234 Claims Department Fax: 020 8350 2350 ENSURE ALL SECTIONS
Rural Insurance Farm Motor
Rural Insurance Farm Motor Policy Summary Rural Insurance agricultural and rural insurance specialists Tel: 01423 876 000 Fax: 01423 876 001 Email: enquiries@ruralinsurance.co.uk ruralinsurance.co.uk Farm
Motor accident. Claim form. telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie 06/08 FI 44766
Zurich House Ballsbridge park Dublin 4 telephone 01 667 0666 fax 01 667 0644 website www.zurich.ie ZURICH INSURANCE IRELAND LIMITED IS REGULATED BY THE FINANCIAL REGULATOR Claim form Motor accident 30
MOTOR VEHICLE ACCIDENT CLAIM FORM
MOTOR VEHICLE ACCIDENT CLAIM FORM Insurer: Insured Identity No.: Occupation: Phone No.: Vehicle Reg No.: Date Purchased: Make: Tare: Gross Vehicle Mass: Kilometers: Price Paid: Value: Year: Model: If the
Tradewise Insurance Company Ltd
Tradewise Insurance Company Ltd MOTOR ACCIDENT REPORT FORM Ensure all sections of this form are completed fully. Also note that any attempt to defraud Underwriters will result in criminal prosecution.
MOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd MOTOR TRADE ROAD RISKS ACCIDENT REPORT FORM Link House 292-308 Southbury Road, Enfield, Middlesex EN1 1TS Tel: 0844 620 1234 Claims Department Fax: 020 8350 2350 ENSURE
MOTOR ACCIDENT CLAIM FORM
MOTOR ACCIDENT CLAIM FORM Broker details Broker name Claim number: Jhb Policy number: Jhb Certificate number Insured details Full name and surname Occupation ID VAT number Postal and code Work tel Home
Public / Employer Liability Claim Form
Public / Employer Liability Claim Form www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent
Motor Accident Report Form
Motor Accident Report Form THIS FORM MUST BE COMPLETED BY THE POLICYHOLDER AND/OR THE AUTHORISED DRIVER PLEASE HELP US TO HELP YOU BY: MAKING SURE THE INFORMATION YOU GIVE IS AS TRUTHFUL AND ACCURATE AS
Property Claim Form. www.towergateunderwriting.co.uk
Property Claim Form www.towergateunderwriting.co.uk Guidance Notes Most delays in settling claims arise because claim forms are not fully completed or requested documents are not sent to us. We would therefore
VEHICLE ACCIDENT CLAIM FORM
Please help us to help you by: completing all relevant questions in full as this can avoid the need for further enquiry and possible delay in settling your claim signing and dating page 7 of this form
Holburn Holdings (Pty) Limited Insurance Brokers VAT No. 4690259439
Holburn Holdings (Pty) Limited Insurance Brokers VAT No. 4690259439 Block C, Abrey Eco Park, 5 Abrey Road, Kloof, 3610 FSP Licence No. 45159 P.O. Box 198, Gillitts, 3603 031 7640481 Fax: 031 7640178 or
Claim form Motor accident
Claim form Motor accident 30 EAGLE STAR INSURANCE COMPANY (IRELAND) LTD CGL 25495 A member of the Zurich Financial Services Group www.eaglestar.ie Motor accident Policy number: Claim number: This form
MOTOR FLEET INSURANCE PROPOSAL FORM
1. Details of Proposer(s): Trading Name (If any): Correspondence Address: Tel: Fax: Mobile: E-mail: Business or Occupation: Company website address (if any): 2. Details of Vehicles: Sr.. Manufacture Make
MOTOR FLEET PROPOSAL FORM
MOTOR FLEET PROPOSAL FORM One Coval Wells Chelmsford Essex CM1 1WZ Tel: 01245 272700 Fax: 01245 272701 QBE European Operations is a trading name of QBE Insurance (Europe) Limited, no. 01761561 ( QIEL ),
Motor Incident Claim Form
Motor Incident Claim Form Policy number Claim number This form should be filled in by the person named as the policyholder on the policy schedule. For accident reporting, please complete all sections on
Motor Trade Road Risks. Proposal Form
Motor Trade Road Risks Proposal Form PLEASE ANSWER ALL QUESTIONS FULLY IN BLOCK CAPITALS If there is insufficient space for any answers please continue on the back page 1. PROPOSER Mr Mrs Miss Ms Surname
O LEARY INSURANCE GROUP
PART A - POLICYHOLDERS DETAILS Your name: Your Insurer + Policy Number: Your address: Your e-mail address (if any): Your occupation: Phone numbers Daytime: Evening: Mobile: Fax: Are you registered for
MOTOR ACCIDENT CLAIM FORM
MOTOR ACCIDENT CLAIM FORM Please do not obtain any quotations. We will appoint an Assessor to assess the damage to your vehicle. Clear copy of Driver s licence to be submitted with claim form. Insured
MOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM How to obtain a quick response to your claim: 1. Make sure that you fully answer all questions 2. Attach a copy of the Driver s Licence for the driver of the vehicle at the time
MOTOR FLEET. Proposal Form November 2004 Edition
MOTOR FLEET Proposal Form vember 2004 Edition Important tice To apply for the Motor Fleet Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink). You
MOTOR ACCIDENT MARINE CLAIM FORM
Please complete in full the relevant sections and submit it to:, P.O. Box 45, Regal House, Queensway,. If any sections are not applicable please add N/A. INSURED Full Name: Policy No.: Postcode: Business
Autovan Commercial Motor Insurance Proposal form
Autovan Commercial Motor Insurance Proposal form Agent s name Agent s number Policy number te: Please use BLOCK CAPITALS and tick YES or NO where appropriate. Please initial any alterations. A. Proposer
MOTOR VEHICLE INSURANCE PROPOSAL FORM
MOTOR VEHICLE INSURANCE PROPOSAL FORM In completing the Proposal Form please ensure that questions are answered fully and accurately and where necessary schedules giving further explanation are provided.
fleetshield proposal form
fleetshield proposal form FOR OFFICE USE ONLY: Policy.: Authorised: Agency: Broker/Agent: Quote Ref.: premium: A full policy wording is available on request Important: It is an offence under the ROAD TRAFFIC
Autovan Commercial Motor Insurance Proposal form
Autovan Commercial Motor Insurance Proposal form Agent s name Agent s number Policy number te: Please use BLOCK CAPITALS and tick YES or NO where appropriate. Please initial any alterations. A. Proposer
1.8 Organisation details. Name
Claim form Please read our booklet Guide to making a Motor Insurers Bureau claim before you fill in this form. The booklet gives information about the MIB and how we deal with claims. l Please complete
Motor Vehicle Claim Form
phone: +64 9 377 4314 fax: +64 9 373 4882 email: claims@icib.co.nz web: www.icib.co.nz Level 7, 26 Hobson Street Auckland, PO Box 3174 Auckland 1140, New Zealand Motor Vehicle Claim Form Policy Details
Motor Accident Claim Form Insured Section
Motor Accident Claim Form Insured Section Date Insured Name Insured Licence Code Licence : Date of Issue Insured Id Policy Insured Address Suburb Town Province Code Contact Person Landline Number Fax Number
MOTOR ACCIDENT CLAIM FORM
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
COMMERCIAL VEHICLE INSURANCE PROPOSAL
Tradewise Insurance Services Ltd COMMERCIAL VEHICLE INSURANCE PROPOSAL SUMMARY OF COVER This is a brief outline only - a copy of the policy wording including all terms and conditions may be obtained on
CLAIM FORM A. To be completed by the registered operator/ owner or driver of the vehicle
Notice of Accident CLAIM FORM A To be completed by the registered operator/ owner or driver of the vehicle If you have suffered Personal Injury resulting directly from this motor accident and wish to claim
COMMERCIAL VEHICLE ACCIDENT REPORT FORM
Tradewise Insurance Services Ltd COMMERCIAL VEHICLE ACCIDENT REPORT FORM 300 Southbury Road Enfield, Middx EN1 1TS Tel: 0344 620 1234 Claims Department Fax: 020 8350 2350 Driving entitlement consent form
Private Car Insurance
Private Car Insurance Proposal form Agent s name Agent s number Policy number tes Please use BLOCK CAPITALS and tick YES or NO where appropriate and initial any amendments. A Proposer Title (Mr, Mrs, Miss
MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE
MOTOR TRADE ROAD RISKS ANNUAL DECLARATION COVER ENGINEERED FOR THE MOTOR TRADE Motor Trade Road Risks Important Note You (or the broker or agent completing the form on your behalf) must provide all material
1.8 Organisation details Name. Address. 1.9 Is the organisation VAT registered?
Claim form You must read our booklet Motor Insurers' Bureau, Making a claim before you fill in this form. The booklet gives information about the MIB and how we deal with claims. Please use black ink and
Telephone numbers Home Work Mobile. Are you the registered owner? Yes No. Was an immobiliser fitted to the vehicle? Yes No
Motor Theft Claim Form Please help us to help you by: making sure the information you give is as clear and complete as possible completing all the relevant sections of this form remembering to sign and
HAULAGE VEHICLE INSURANCE. Proposal Form November 2004 Edition
HAULAGE VEHICLE INSURANCE Proposal Form vember 2004 Edition Important tice To apply for the Haulage Vehicle Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue
ORCHESTRALGUARD LIABILITY CLAIM GUIDANCE NOTES
insuring the UK s orchestral musicians ORCHESTRALGUARD LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of
Farm Motor Proposal - Information andMotor Vehicle Insurance
Farm Motor Proposal www.towergateunderwriting.co.uk MOTOR PROPOSAL Please read the following important notes before completing this proposal WARNING If you are in any doubt about a particular fact(s) being
COMMERCIAL VEHICLE PROPOSAL FORM YOU LL ONLY NEED TO WORRY ABOUT THE TRAFFIC
COMMERCIAL VEHICLE PROPOSAL FORM YOU LL ONLY NEED TO WORRY ABOUT THE TRAFFIC Introduction Choice of Cover Third Party Fire and Theft You are covered for liability to third parties (including passengers)
MOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM (If there is not enough room on this form for your answers, please attach a separate sheet, indicating the Section and Question you wish to complete.) Please lodge your claim to
LIABILITY CLAIM GUIDANCE NOTES
LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you by any third party, for damage
COMMERCIAL MOTOR CLAIM FORM
COMMERCIAL MOTOR CLAIM FORM Please complete in full all sections of this claims form and return it to Insuret as soon as possible after the accident. Unless specifically arranged beforehand, no repairs
Motor Vehicle. Claim Report
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
Claim Form. Motor Vehicle. Section 1 (To be completed by Owner): Occupation. Name of insured. Address. Phone No [ ] Year Model.
![Claim Form. Motor Vehicle. Section 1 (To be completed by Owner): Occupation. Name of insured. Address. Phone No [ ] Year Model.](/thumbs/25/4774397.jpg "Claim Form. Motor Vehicle. Section 1 (To be completed by Owner): Occupation. Name of insured. Address. Phone No [ ] Year Model.")
Section 1 (To be completed by Owner): Policy no Name of insured Occupation Expiry Date Phone No [ ] Make of Vehicle Mileage Registration No Year Model Co-Owner In whose name is the registered? For what
How To Fill Out A Claim Form For A Car Accident In The Uk
Motor Vehicle Claim Report Please retain this page for your information IMPORTANT INFORMATION ABOUT YOUR CLAIM This form must be completed and signed by the person who was driving your vehicle, or the
HEAVY MOTOR FLEET INSURANCE CLAIM FORM
HEAVY MOTOR FLEET INSURANCE CLAIM FORM Take precautions to ensure that no further damage or loss occurs to the vehicle. Where possible have the vehicle moved to a secure location if not drivable. Obtain
BRITISH CYCLING BIKE INSURANCE DAMAGE CLAIM GUIDANCE NOTES
BRITISH CYCLING BIKE INSURANCE DAMAGE CLAIM GUIDANCE NOTES Please note that in order to process your claim with optimum efficiency we will require receipt of the necessary documentation as outlined in
ROAD RISKS PROPOSAL FORM
ROAD RISKS PROPOSAL FORM Granite Underwriting limited Form GU-VRR002 Daniel House, 36 Chapel Lane, Formby, Merseyside L37 4DU Completed proposal forms should be returned to the above address. Data Protection
Motor vehicle insurance claim form
Motor vehicle insurance claim form Suva: 231 Waimanu Rd Phone: 331 1055 Fax: 330 3475 Nadi: Main Street Phone: 670 1451 Fax: 6701221 Important Notes To assist Dominion Insurance Limited ( us/our/we ) process
Liability Claims Guidance Notes
Liability Claims Guidance Notes It is important that you read and understand these guidance notes before When can a claim be made against the Council? completing the claim form To successfully claim compensation
Important message for customers wishing to make a claim on their policy
Important message for customers wishing to make a claim on their policy Before we can action your claim, can you please : Fully complete the attached claim form If your vehicle is driveable, call us to
LIABILITY CLAIM GUIDANCE NOTES
insuring the UK s triathletes LIABILITY CLAIM GUIDANCE NOTES In the unfortunate event of a claim, we will do everything possible to deal with your claim promptly. In respect of claims made against you
East African Underwriters Ltd
East African Underwriters Ltd 3 rd Floor 99 Buganda Road. P.O Box 22938, Kampala, Uganda Tel: 0312246500 E-mail: eaul@eaunderwriters.com QUESTIONNAIRE & PROPOSAL FOR COMMERCIAL VEHICLE INSURANCE NB. All
Proposal Form Commercial Vehicle
Commercial Vehicle for your commercial vehicle insurance Introduction About NIG Thank you for choosing NIG as your Commercial Vehicle insurer. We have been established for over 100 years and provide insurance
NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel- 0114873901-905, Fax -0112431145. Motor Accident Claim forms
NATIONAL INSURANCE TRUST FUND No: 70, D.R. Wijewardana Mawatha, Colombo-10 Tel- 0114873901-905, Fax -0112431145 Motor Accident Claim forms Please complete this form in Block Capitals. Answer all questions
MOTOR CLAIM FORM. Policy Number Claim Number Your reference. Make and model Vehicle c.c. Year of manufacture
PLEASE ANSWER EVERY QUESTION. MOTOR CLAIM FORM Policy Number Claim Number Your reference INSURED Post code Telephone Number Department Concerned (Code and Description) VAT registered / status? VEHICLE
EVANS CYCLES INSURANCE THEFT CLAIM GUIDANCE NOTES
EVANS CYCLES INSURANCE THEFT CLAIM GUIDANCE NOTES Please note that in order to process your claim with optimum efficiency we will require receipt of the necessary documentation as outlined in the following
MOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
claim form home insurance Section 1 Details of policyholder Prior to submitting a claim
home insurance claim form Name Address Policy number: Claim number: (If known) Prior to submitting a claim If the loss or damage is extensive please contact your broker or intermediary or Integra claims
CLAIM FORM PLEASE ENSURE ALL SECTIONS ARE COMPLETED IN BLOCK CAPITALS, USING BLACK INK POLICYHOLDER DETAILS
CLAIM FORM PLEASE ENSURE ALL SECTIONS ARE COMPLETED IN BLOCK CAPITALS, USING BLACK INK Our Ref: Broker: Policy/Certificate number: Period of cover: Date claim first notified: POLICYHOLDER DETAILS Name:
1. Your Details 2. Insured Vehicle Description
MOTOR VEHICLE CLAIM The issue or acceptance of this form is not to be construed as an admission of liability on the part of the company. Shaded areas for office use only. Please print clearly. Claim Number
ACCIDENT-@LL CLAIM FORM (page 1) Name:.. Address:...Post Code:... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:..
CLAIM FORM (page 1) DRIVER DETAILS Address:........Post Code:..... Sex M/F D.O.B. Age:... Tel:.. Mobile:. Occupation:. Name & Address of Employer:.. NI No:. CAR DETAILS Registration No:... Make & Model:...
Motor Vehicle Claim Form
Motor Vehicle Claim Form Dear Policyholder, We re sorry to hear you ve had an accident. Our aim is to settle your claim as quickly as possible. You can help us do this by ensuring the enclosed claim form
MOTOR VEHICLE ACCIDENT Claim Report
MOTOR VEHICLE ACCIDENT Claim Report HBA General Insurance and Mutual Community General Insurance Insurer: Mutual Community General Insurance Pty Ltd Abn 59 007 895 543 Please retain this page for your
This can be checked on the Financial Services Register by visiting the FCA s website at www.fca.org.uk/firms/systems- reporting/register
Motor Excess Protect Thank you for choosing Motor Excess Protect Insurance. The information in this policy wording contains important information and We have made it as easy as possible to understand.
MOTOR VEHICLE CLAIM FORM
MOTOR VEHICLE CLAIM FORM The Issue of this Form is not an Admission of Liability by Insurers We understand the difficulties arising from your accident. Please complete and return this claim form as soon
Motor Fleet Proposal Form
Motor Fleet Proposal Form Section 1: General Name of Proposer: Trading Name: Address: Years trading: Have you traded in another name? (If please provide details) Are you associated with any other companies?
Motor Fleet Proposal Form
Motor Fleet Proposal Form Important tes Material Facts Failure to disclose material facts could result in your policy being invalidated. Material facts are those facts which might influence the acceptance
Personal Accident Claim Form
Personal Accident Claim Form Accident & Sickness www.towergateunderwriting.co.uk Guidance Notes Accident and Sickness Most delays in settling claims arise because claim forms are not fully completed or
1. Injured Persons Position in in Vehicle (PLEASE PRINT NEATLY USING CAPITAL LETTERS)
Common Law Law Claim Claim Form Form Please answer all all questions and and tick tick boxes boxes where where appropriate. Leaving Leaving a question a question blank blank may may delay delay the processing
RSA Household Insurance Claim Form and Guidance Notes
RSA Household Insurance Claim Form and Guidance Notes Customer Service Customer Complaints Procedure We are anxious to provide the highest quality of customer service at all times. We are eager therefore
Application for Scheduled Benefits
Application for Scheduled Benefits CLAIM FORM B To be completed by, or on behalf of, an injured driver/ passenger/motorcyclist/pillion passenger/pedestrian/cyclist Please also complete Claim Form A Notice
Motor Fleet Insurance Proposal Form
Motor Fleet Insurance Proposal Form This proposal for motor fleet insurance forms the basis of the contract between you (the Proposer) and us (the Insurer). Failure to disclose all relevant information
2. The Insured (Vehicle owner)
mobile plant liability claim form WFI Insurance Limited, ABN 24 000 036 279 The issue of this form must not be taken as an admission of liability. Form is to be completed as far as possible by the driver
Protection for business Motor Fleet Insurance
Protection for business Motor Fleet Insurance Haulage Factfinder Motor Fleet Insurance Haulage Factfinder The information you provide in this form will be used to assess your motor fleet insurance risk
Motor Vehicle Claim Form
SSAA Insurance Brokers Pty Ltd Phone (08) 8332 0281 The Precinct Freecall 1800 808 608 Suite 14, 539 Greenhill Road Facsimile (08) 8332 0303 539 Greenhill Road Email insurance@ssaains.com.au Hazelwood
Motor Vehicle Claim Form
1st Floor, 50 Hindmarsh Square Adelaide SA 5000 PO Box 6095 Halifax St Adelaide 5000 Phone 08 8413 6300 Facsimile 08 82119838 enquiries@brecknock.com.au brecknock.com.au Motor Vehicle Claim Form We re
Allianz Insurance plc. Small Fleet. Information including Policy Summary (pages 1-3) and Proposal Form (pages 5-6)
Allianz Insurance plc Small Fleet Information including Policy Summary (pages 1-3) and Proposal Form (pages 5-6) Introduction Thank you for choosing Allianz Insurance plc. We are one of the largest general
Employers Liability Claim Form
Claims Reference No. (if known) Employers Liability Claim Form 1. You the Policyholder of Insured Postcode Contact Number Policy Number Business Date Premium Paid Are you a Registered Trade for VAT purposes?
SECTION 2 Insurance March 2014
SECTION 2 Insurance March 2014 Paragraph Insurance 2.1 Accident/Insurance Claims 2.2 Insurance Cover whilst travelling abroad 2.3 Windscreen/Windows Replacement Service 2.4 Loan of County Minibus Vehicles
COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS
COMMERCIAL INSURANCE PROPOSAL FORM COVER DESIGNED FOR YOUR BUSINESS This Proposal is for use by special agreement with NIG in connection with their range of Commercial Non-motor Policies other than Motor
Motor Vehicle Accident Report Form
Motor Vehicle Accident Report Form 1300 725 788 Your Car, Your Choice Know Your Rights Service & Quality Guaranteed One Call Does It All Owner s Particulars (PLEASE COMPLETE IN BLOCK LETTERS) Full Name
MOTOR VEHICLE CLAIM FORM (Accident or Theft)
Cowden Group MOTOR VEHICLE CLAIM FORM (Accident or Theft) The supply or acceptance of this form is not an admission of liability on the part of your Insurer 1. Your Details Policy No Expiry of Insured
Motor Vehicle Insurance Claim
Motor Vehicle Insurance Claim The supply or acceptance of this form is not an admission of liability on the part of the insurer. Please complete ALL sections of this claim form. Unless specifically arranged
secure boat claim form
secure boat claim form NOTES: The issue of this Claim Form is not an admission of liability on our part. All questions must be fully answered in either black or blue pen. Please print clearly and tick
Details of Helivac RAC Claim
Details of Helivac RAC Claim A. Claimant details 1. Title: 2. Surname: 3. Name: 4. Date of birth: 5. ID number / Passport number: Note: A certified legible copy of your identity document must be attached
Motor Accident Personal Injury Claim Form
Motor Accident Personal Injury Claim Form HAVE YOU BEEN INJURED IN A MOTOR VEHICLE ACCIDENT? If you have been injured in a motor vehicle accident in New South Wales, you may be able to access benefits