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MOTOR ACCIDENT REPORT

PLEASE NOTE: An agent who completes a Proposal Form does so as an agent of the proposer.

It is essential that every question with * be answered fully for proper processing of the form.

POLICY NO.

(a)

Full Name of Insured *

(b)

Full Postal Address *
(to which all correspondence would be sent)

(c)

Occupation
(Pls give full details)

(d)

Mobile Tel. No. *

(e)

Tel. No.

(f)

E-mail Address *

(g)

Inception Date

(h)

Branch

VEHICLE INSURED PARTICULARS

		Vehicle
a.	Make of each vehicle *
b.	Registration no. *
c.	CC
d.	Year of manufacture
e.	Engine Number
f.	Chasis Number
g.	Mileage Covered
h.	Purpose being used
If commercial, type of use
i.	Own Goods
j.	Goods only
k.	General Cartage
l.	Taxi/Bus
m.	If Taxi/Bus How many passengers

DRIVER AT THE TIME OF ACCIDENT

Name			Age
Address
Is Driving License in force?			If yes, which category
Driving Licence No.			Has it been endorsed?
Date of Issue			Date of Expiry
Place of Issue
Is it a Learners' Permit?			If so, Number
Period
Relation of Driver to Insured			If Paid Driver, for how long employed
Does Driver own a vehicle?
If so, Name and Address of Insurer

PARTICULARS OF ACCIDENT

Date			Time
Exact Location of Accident
Road Condition			Weather Condition
Speed of your Vehicle			Condition of brakes
If object collided with what was moving, what direction was it going
Address of Police Station Accident was reported
No. of Person in (i) Insured Vehicle			The Other Vehicle

Full Description of accident

WITNESS			OCCUPANTS OF YOUR VEHICLE
Name			Name
Address			Address
Name (2)			Name (2)
Address (2)			Address (2)

DAMAGE TO INSURED VEHICLE

Full details of Damaged Parts
Present Location of Vehicle
Rough Estimate of Repairs
Repairer's Name and Address
Inventory of Damaged Parts

THIRD PARTIES INVOLVED IN THE ACCIDENT

Name
Address
Type of property/Injury
If Vehicle, Make
Registration No
Year of Make
Present location of Vehicle
Is Owner Insured
If Yes; Policy No.
Name and Address of Insurer

DECLARATION - I/We declare the foregoing particulars to be true and I/We authorize LEADWAY ASSURANCE COMPANY LIMITED and/or their Legal representatives to deal with all matters arising from this accident at their discretion and if they deem it expedient to admit liability and/or negligence on the part of myself/our servants or Agents

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