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Motor Vehicle
 Client No.
TOWER
Claim Form
 Agency No.
Insurance

ISSUE OF THIS FORM DOES NOT CONSTITUTE AN ADMISSION OF THE COMPANY'S LIABILITY. NO LIABILITY IS TO BE ADMITTED TO A THIRD PARTY. NO REPAIRS ARE TO BE DONE WITHOUT THE PERMISSION OF THE COMPANY. IF YOU RECEIVE ANY COMMUNICATION IN ANY WAY CONNECTED TO THE ACCIDENT PLEASE FORWARD TO THE COMPANY IMMEDIATELY.

CLIENT NO.
POLICY NO.
DUE DATE
EXCESS
SUM INSURED
CLAIM NO.
NAME: Ph WORK:
ADDRESS: Ph HOME:  
MORTGAGEE/LESSOR: FAX:          
MAKE & TYPE OF BODY
YEAR MODEL
ENGINE NO.
REGO NO.
PURPOSE OF USE AT TIME OF ACCIDENT
NO. OF PASSENGERS OR WEIGHT OF LOAD
DRIVER DETAILS
1. IN WHOSE NAME IS THE VEHICLE REGISTERED?
2. PLEASE STATE IF VEHICLE IS UNDER HIRE PURCHASE (AND AMOUNT OWING)
3. GIVE ADDITIONAL PARTICULARS IF YOU ARE OTHERWISE NOT THE SOLE OWNER
4. DOES THE DRIVER OWN HIS OWN VEHICLE (AND THE NAME OF HIS INSURANCE COMPANY)?

5. HAS THE DRIVER EVER HAD A POLICY OF INSURANCE CANCELLED OR DECLINED OR AN EXCESS OR INCREASED PREMIUM IMPOSED?
6. WHAT AMOUNT OF LIQUOR WAS CONSUMED BY THE DRIVER DURING THE 12 HOURS PRECEEDING THE ACCIDENT, INCLUDING WHEN AND WHERE?

7. PLEASE ADVISE IF IN CONNECTION WITH THE ACCIDENT POLICE ACTION HAS BEEN THREATENED (CHARGED AND IDENTITY OF PERSON REQUIRED)


DETAILS OF DAMAGE TO INSURED VEHICLE:
1. DETAILS OF DAMAGE
2. IS IT IN A FIT CONDITION TO DRIVE?
3. AMOUNT OF ESTIMATE FOR REPAIRS (ATTACH QUOTE IF POSSIBLE)
4. WHERE AND WHEN CAN IT BE INSPECTED

NAME AND ADDRESS OF OTHER PARTY
VEHICLE TYPE AND REGISTRATION NUMBER

PLEASE GIVE NAMES AND ADDRESSES OF ALL WITNESSES:
PASSENGERS IN VEHICLE A PHONE NUMBER
PASSENGERS IN VEHICLE B PHONE NUMBER
PASSENGERS IN VEHICLE C PHONE NUMBER
INDEPENDENT WITNESS A PHONE NUMBER
INDEPENDENT WITNESS B PHONE NUMBER
POLICE OFFICER'S NAME & NUMBER STATIONED AT   
IS THERE ANY LIKELYHOOD OF POLICE ACTION BEING TAKEN? AGAINST WHOM

PLEASE MAKE A ROUGH PLAN OF ROAD SHOWING DISTANCE AND POSITIONS OF ALL VEHICLES AND PERSONS CONCERNED SHOWING BY ARROWS THE DIRECTION THEY WERE TRAVELLING. YOUR VEHICLE TO BE MARKED (A) AND THE OTHER PARTIES (B), (C) AND SO ON, WITH POINT OF IMPACT SHOWN.

DATE OF ACCIDENT: TIME: A.M./P.M. PLACE
PLEASE DESCRIBE WHERE YOU HAD BEEN AND WHERE YOU WERE GOING
YOUR SPEED PRIOR TO IMPACT K.P.H.      OTHER PARTIES SPEED PRIOR TO IMPACT K.P.H.
WARNING SIGNALS GIVEN BY EITHER PARTY
WHOM DO YOU CONSIDER RESPONSIBLE FOR THE ACCIDENT AND WHY?

GENERAL DESCRIPTION OF THE ACCIDENT

STATE CLEARLY CONVERSATIONS BETWEEN YOU AND THE OTHER DRIVER.

I declare the articulars on pages 1 and 2 of this form to be true and correct in every respect and that the completion of this form and the signing of it is a claim on the Company and not only a notice of accident. I further acknowledge that any untruth, misrepresentation or suppression by or on behalf of me in any declaration or statement in support of the claim made herein makes the policy under which this claim is made void and the premium forfeitable.
Dated at This day 20
Insured's Signature Witness to Signature