Online Claim Submission
Insured Name
Policy Number
Contact #
Email
Location Address
Postal Address
Mode of Contact
Name of Insurance Company (if insured elsewhere)
Vehicle Reg. Number
Vehicle Make
Vehicle Model
Chasis Number
In whose name is Vehicle Registered?
Vehicle in whose possesion when accident occurred?
Where can the accident vehicle be located?
Name of Driver at time of accident
Driver First License Date (original would be needed)
Address of Driver
Phone No. of Driver
License No. of Driver
Date of Accident
Accident_Time
Speed
Where was the vehicle headed?
Place of Accident
What was the vehicle being used for
Did the user obtain insured's consent (if driver not the insured)?
Was the vehicle carying any goods?
If yes, then what type of goods?
Were there any fare-paying passengers?
If yes then How many passengers?
Were there any injuries?
Who is to blame for the accident?
Name of who is to blame
Address of who is to blame
Contact Number of who is to blame
Insurance details of who is to blame
When was the accident reported to the Police?
Which Police Station?
Name of Police Officer handling accident?
Did the Police take any evidence or particulars?
Were there people at the scene of accident?
Name of Witness 1
Contact# of Witness 1
Name of Witness 2
Contact# of Witness 2
Name of Witness 3
Contact# of Witness 3
Details of damage DIRECTLY from the accident
Please describe how the accident occurred
Were there any third party property/vehicle(s) involved?