Motor Accident Claims Form Jan 11, 2019by Darryl Bome Motor Accident Claims Form Share SECTION 1: INSUREDSECTION 2: VEHICLESection 3: DAMAGEIs your vehicle under warranty<p>Is your vehicle under warranty</p>YesNoIs your vehicle under a motor plan?<p>Is your vehicle under a motor plan?</p>YesNoSection 4: DRIVERWas he/she driving with permission?<p>Was he/she driving with permission?</p>YesNoHas license ever been endorsed?<p>Has license ever been endorsed?</p>YesNoHas he/she any physical defects?<p>Has he/she any physical defects?</p>YesNoYesNoSection 5: Passengers (insured vehicle)- Injury -YesNo- Injury -YesNo- Injury -YesNoSection 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 Passenger Injury:YesNoSection 7: AccidentSpeed traveling<p>Speed traveling</p>Was the drive tested for alcohol or drugs?<p>Was the drive tested for alcohol or drugs?</p>YesNoRoad surface<p>Road surface</p>TarGravelOff-roadI / 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>Driver SignatureInsured SignatureSubmit
