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Home » Commercial Insurance » Quotes and Forms » Forms
  MOTOR THEFT/FIRE CLAIM FORM  
     
 

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) Fax No.  
(g) E-mail Address *  
(h) Inception Date  
(i) 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 were carried at the time of loss?
3. PERSON IN CHARGE OF THE VEHICLE AT THE TIME OF THEFT/FIRE ACCIDENT
 
Name   Age
Address    
Was the Vehicle used with your permission?  
For what purpose was it used at the time of loss?  
Are there any other insurance cover on the vehicle?  
If so, give policy Nos & Names of Insurers  
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 THEFT/FIRE INCIDENT
 
Who discovered the loss?    
Date of incident   Time
Exact Location of Accident    
Cause of Fire   Speed of vehicle
Did Fire Brigade attend? If so, which station
Did Police attend?   If so, which station
5.
FULL STATEMENT OF THEFT/FIRE INCIDENT
 
6.
Who do you suspect for the loss?
When did you last service the vehicle?
By whom, at where?
7.
WITNESS   OCCUPANTS OF YOUR VEHICLE
Name   Name
Address   Address
Name (2)   Name (2)
Address (2)   Address (2)
8. 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
9. 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
   
  If notice of third party claim has been given verbally or in writing, give full particulars:
  If any written communication is recieved, please forward it immediately unanswered:
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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