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Home » Commercial Insurance » Quotes and Forms » Forms
  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.
1.
(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  
 
2. 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
3. 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      
4. 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
5.
Full Description of accident
 
6.
WITNESS   OCCUPANTS OF YOUR VEHICLE
Name   Name
Address   Address
Name (2)   Name (2)
Address (2)   Address (2)
7. 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
8. 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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