Motor Accident Claims Form Jan 11, 2019by Darryl Bome Motor Accident Claims Form Share Policy NumberField is required!Field is required!SECTION 1: INSUREDName & Surname:Field is required!Field is required!ID NumberField is required!Field is required!Email AddressField is required!Field is required!OccupationField is required!Field is required!AddressField is required!Field is required!Cell NumberField is required!Field is required!Work NumberField is required!Field is required!Home NumberField is required!Field is required!SECTION 2: VEHICLERegistrationField is required!Field is required!YearField is required!Field is required!MakeField is required!Field is required!ModelField is required!Field is required!Section 3: DAMAGERepairer NameField is required!Field is required!Repairer Telephone:Field is required!Field is required!Repairer AddressField is required!Field is required!Damage to own vehicleField is required!Field is required!Current location of vehicleField is required!Field is required!Is your vehicle under warranty<p>Is your vehicle under warranty</p>YesNoField is required!Field is required!Full description of broken or lost glassField is required!Field is required!Is your vehicle under a motor plan?<p>Is your vehicle under a motor plan?</p>YesNoField is required!Field is required!Windscreen clear, tinted, shatterproof or armour plateField is required!Field is required!Section 4: DRIVERDriver Name and SurnameField is required!Field is required!Driver ID NumberField is required!Field is required!Driver Email addressField is required!Field is required!Driver OccupationField is required!Field is required!Driver AddressField is required!Field is required!Driver Cell NumberField is required!Field is required!Driver Work NumberField is required!Field is required!Driver Home NumberField is required!Field is required!Was he/she driving with permission?<p>Was he/she driving with permission?</p>YesNoField is required!Field is required!Has license ever been endorsed?<p>Has license ever been endorsed?</p>YesNoField is required!Field is required!Has he/she any physical defects?<p>Has he/she any physical defects?</p>YesNoField is required!Field is required!Purpose for which vehicle was being usedField is required!Field is required!Drivers license first issue dateField is required!Field is required!License CodeField is required!Field is required!YesNoField is required!Field is required!Details of any convictions for motoring offences Field is required!Field is required!Details of previous accidents:Field is required!Field is required!Section 5: Passengers (insured vehicle)Passenger 1 Name & SurnameField is required!Field is required!Passenger AddressField is required!Field is required!- Injury -YesNo- Injury -Field is required!Field is required!Passenger 2 Name & SurnameField is required!Field is required!Passenger AddressField is required!Field is required!- Injury -YesNo- Injury -Field is required!Field is required!Passenger 3 Name & SurnameField is required!Field is required!Passenger AddressField is required!Field is required!- Injury -YesNo- Injury -Field is required!Field is required!Section 6: Third Party (damage to other vehicles/ property)NB: Please notify the Insurers immediately if you become aware of any impending prosecution, inquest or demand!<p>NB: Please notify the Insurers immediately if you become aware of any impending prosecution, inquest or demand!</p>Third Party Name and Surname (Owner and/or Driver)Field is required!Field is required!Third Party ID NumberField is required!Field is required!Third Party OccupationField is required!Field is required!Third Party AddressField is required!Field is required!Third Party Cell Number:Field is required!Field is required!Third Party Work NumberField is required!Field is required!Third Party Home NumberField is required!Field is required!Third Party Vehicle RegistrationField is required!Field is required!Third Party Details of DamageField is required!Field is required!Third Party PassengerField is required!Field is required!Third Party Vehicle MakeField is required!Field is required!Third Party Insurance DetailField is required!Field is required!Third Party Passenger Address:Field is required!Field is required!Third Party Passenger Injury:YesNoThird Party Passenger Injury:Field is required!Field is required!Details of InjuryField is required!Field is required!Section 7: AccidentSelect a dateField is required!Field is required!Select a timeField is required!Field is required!PlaceField is required!Field is required!Police StationField is required!Field is required!Reference NumberField is required!Field is required!Police OfficerField is required!Field is required!Speed traveling<p>Speed traveling</p>Before Accident (km/h):Field is required!Field is required!At ImpactField is required!Field is required!Was the drive tested for alcohol or drugs?<p>Was the drive tested for alcohol or drugs?</p>YesNoField is required!Field is required!Weather conditionsField is required!Field is required!VisibilityField is required!Field is required!Road surface<p>Road surface</p>TarGravelOff-roadField is required!Field is required!Description of accidentField is required!Field is required!I / we declare that to the best of my/our knowledge the above information is true in every aspect. NB I acknowledge that should I elect to use a non-manufacturer approved repairer I release Pogo Group from any liability which could arise as a result of any defective workmanship. I acknowledge further that I may lose my manufacturer’s warranty and or maintenance plan that may exist on my vehicle.<p>I / we declare that to the best of my/our knowledge the above information is true in every aspect.</p><br /> <p><strong>NB</strong> I acknowledge that should I elect to use a non-manufacturer approved repairer I release Pogo Group from any liability which could arise as a result of any defective workmanship. I acknowledge further that I may lose my manufacturer’s warranty and or maintenance plan that may exist on my vehicle.</p>Witness Name and SurnameField is required!Field is required!Witness AddressField is required!Field is required!Witness Contact NumberField is required!Field is required!CapacityField is required!Field is required!DateField is required!Field is required!DateField is required!Field is required!Submit
