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Motor_Accident_Claim_Form

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Motor_Accident_Claim_Form Powered By Docstoc
					                                           Head Office: Corner Duke & Abercromby Street, Port of Spain, Trinidad W.I.
     Telephone: (868) 623-2201-3/5                       Fascimile: (868) 623-0925                     E-mail: info@colfire.com                   Website: http://www.colfire.com

                                                                  MOTOR ACCIDENT CLAIM FORM
     It is essential that all questions are fully answered whether of not a Claim is being made against the Policy. Completing all questions will expedite the processing.settlement of the claim.

1.   POLICYHOLDER'S INFORMATION

     Title:                    First Name:                                                       Middle Initial:                  Surname:


     Address:                                                                                                                     City:


     Telephone No(s).:                  Home:                                                 Work:                                                  Mobile:


     E-mail Address:


     Occupation or Trade:                                                                                                            Policy No:


     Are you V.A.T. registered?                      Yes                          No      If Yes, State your V.A.T. Registration Number:


     Employer's Name:          Title:                        First Name:                                                          Surname:


     Employer's Address:                                                                                                          City:


     Is the vehicle mortgaged?                   Yes                            No               If Yes, with which company

2.   PARTICULARS OF INSURED'S MOTOR VEHICLE

     Registration No:                                        Make and Model of Vehicle:                                                        Colour of Vehicle:


     For what purpose was the Vehicle being used?


     Are there any other Policies of Insurance in force indemnifying you in respect of this accident?                          Yes                No


     If Yes, give particulars / details

3.   PARTICULARS OF DRIVER

     Title:                    First Name:                                                       Middle Initial:                  Surname:


     Address:                                                                                                                     City:


     Telephone No(s).:                  Home:                                                 Work:                                                  Mobile:


     E-mail Address:


     Employer's Name:             Title:                     First Name:                                                          Surname:


     Employer's Address:                                                                                                          City:


     Date of Birth:                                            (YYYY-MM-DD)                   Age:                        Years           Driver's Licence No:


     Date First Issued:                                            (YYYY-MM-DD)                  Renewal / Payment Date:                                                       (YYYY-MM-DD)


     Did the Driver hold a current Driving Licence at the time of the Accident?                       Yes                     No
                                                                                            Page 1 of 4
     PARTICULARS OF DRIVER Continued...
     Did the Driver have any prevoius accidents?               Yes            No


     If Yes, give please give full details:


     Has the Driver ever been convicted of any offence in connection with the driving of a Motor Vehicle within the past four years?        Yes         No


     If Yes, give please give full details:


     Relationship of driver to Insured:


     Was the Vehicle being driven with the Insured's consent and knowledge?                Yes              No


     Is the Driver your paid employee?                     Yes               No         If Yes, how long has he / she been employed?


     Nature of his/her employment:


     Does the Driver own a vehicle?                      Yes            No              Policy No.:


     If Yes, with which Insurance Company is the vehicle insured

4.   DETAILS OF ACCIDENT OR LOSS

     Date of Accident or Loss:                                         (YYYY-MM-DD)              Time:                           (HH:MM)


     Location (street name etc.):


     Was your vehicle on the correct side?                       Yes              No             On the major road?                   Yes          No


     Road Conditions                          WET                    DRY                          OTHER               Please State:


     Weather Conditions:                      SUNNY                  RAINY                        OTHER               Please State:


     Where were you coming from?


     What lights on your vehicle were in use?                                                    What was your travelling speed?                             kmph


     To which Police Station was the Accident / Loss Reported?


     Officer's Name:         Title:                   First Name:                                                 Surname:


     Officer's Badge No:

     State the circumstances causing the Accident / Loss (include name and registration
     no. of other vehicles involved and whether horn was sounded or other warning given).

     In your opinion, who was at fault?                                                          Did such person admit liability?                 Yes        No

5.   WITNESSES OF ACCIDENT

     State Names, Addresses and Ages of the occupants in the Insured Vehicle:



     State Names and Addresses of any Independent Witnesses




     Did Witnesses or Drivers make any statements as to fault at the time?              Yes              No

                                                                                  Page 2 of 4
6.   PARTICULARS OF DAMAGE TO INSURED'S MOTOR VEHICLE

     State details of damage to Insured's vehicle:


     Where is it desired to have repairs carried out?


     Estimated Cost of Repairs:


     Address where damaged vehicle can be seen:

7.   PERSONS INJURED

     (Injured Person 1)                                                                      (Injured Person 2)

     Name:                                                                                   Name:


     Address:                                                                                Address:


     Telephone No(s).:          Home:                                                        Telephone No(s).:         Home:


     Work:                                      Mobile:                                      Work:                                Mobile:


     Date of Birth:                                          (YYYY-MM-DD)                    Date of Birth:                                    (YYYY-MM-DD)


     Details of Injury:                                                                      Details of Injury:




8.   THIRD PARTY PROPERTY DAMAGE(1)
                                                                                             THIRD PARTY PROPERTY DAMAGE(2)

     Owner's Name:                                                                           Owner's Name:


     Address:                                                                                Address:


     Driver's Name:                                                                          Driver's Name:


     Address:                                                                                Address:


     Telephone No(s).:          Home:                                                        Telephone No(s).:         Home:


     Work:                                      Mobile:                                      Work:                                Mobile:


     Registration No.:                                                                       Registration No.:


     Make & Model of Vehicle:                                                                Make & Model of Vehicle:


     Insurer:                                                                                Insurer:


     Policy No.:                                                                             Policy No.:


     Details of Damage:                                                                      Details of Damage:


     Has any intimation of Claim been made upon you, either verbally or in writing?             Yes               No

     Note:      Any written communication should not be answered and forwarded immediately to COLFIRE. If verbal notice has been received, particulars should
                be given above.



                                                                               Page 3 of 4
9.       ADDITIONAL INFORMATION:




     I

     the undersigned do hereby authorized COLFIRE to disclose any information in respect of my Claims history to any Investigator, Adjuster, Insurance Company,
     Regulatory Body or other Authority, and hereby release COLFIRE from any claims and liabilities of any kind in respect of such disclosure except claims and liabilities
     that may arise under this document.

     I certify that the foregoing statement is a true account to the best of my knowledge and belief.



     Date:                                              (YYYY-MM-DD)                                Insured's Signature




     Date:                                              (YYYY-MM-DD)                                Insured's Signature




                                                 Any further information which can be given should accompany these particulars.
                                     Please use a blank sheet of paper to provide additional information where space provided is insufficient.
                                                                       Be sure to attach to the Claim Form.



                                                                                                                          Reset Form             E-Mail Form to COLFIRE

                                                                                     Page 4 of 4

				
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posted:12/30/2011
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