Submit Motor Vehicle Claim

Submit Motor Vehicle Claim

To download the digital version of the webform please click link below

Submitted by mindq on Thu, 11/07/2019 - 08:02
INSURED (applicable for both accident and theft)
Create an email account

Gmail Account

Yahoo Account

Outlook Account

VEHICLE (applicable for both accident and theft)
Has the vehicle been stolen or in an accident?
Accident
Damage
Driver
Drivers Licence
Passenger (Insured Vehicles)
Passengers in insured vehicle
Second Passenger
Third Passenger
Fourth Passenger
Fifth Passenger
Sixth Passenger
Seventh Passenger
DAMAGE TO OTHER VEHICLE
DAMAGE TO SECOND OTHER VEHICLE
DAMAGE TO THIRD OTHER VEHICLE
Damage to Property
Second Damaged Property
PERSONAL INJURIES OF THIRD PARTY (other than in insured vehicle)
e.g pedestrian, driver of the other vehicle
SECOND PERSONAL INJURIES OF THIRD PARTY (other than in insured vehicle)
e.g pedestrian, driver of the other vehicle
THIRD PERSONAL INJURIES OF THIRD PARTY (other than in insured vehicle)
e.g pedestrian, driver of the other vehicle
Witnesses
Second Witness
THEFT
ACCIDENT (applicable for both accident and theft)
Police Details
FILE ATTACHMENTS
One file only.
512 MB limit.
Allowed types: jpg, jpeg, pdf, .
One file only.
512 MB limit.
Allowed types: jpg, jpeg, pdf, .
One file only.
512 MB limit.
Allowed types: jpg, jpeg, pdf, .
Maximum 2 files.
512 MB limit.
Allowed types: jpg, jpeg, pdf, .
Unlimited number of files can be uploaded to this field.
512 MB limit.
Allowed types: jpg, jpeg.
SUBROGATION
I hereby subrogate, transfer and cede to the insurer any and all claims or causes of action of whatsoever kind and nature which I now have or may hereafter have, to recover against any persons as a result of the said occurrence and loss above-described. Also to recover on my behalf from such persons, my excess payment made as a result of the said occurrence. I agree that the insurer may enforce same in such manner as shall be necessary or appropriate for the use and benefit of the insurer, either in its own name or in mine. I will furbish such papers, information, or evidence as shall be within my possession or control for the purpose of enforcing such claim, demand, or cause of action.
 
DECLARATION
We hereby declare the foregoing particulars to be true in every respect
 
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