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Mua Motor Vehicle Editable Claim Form April 2020

This is a motor insurance claim form requesting details about a vehicle accident, including information about the policyholder, drivers, vehicles involved, circumstances of the accident, damages, witnesses, and a declaration signed by the driver and policyholder. The form notes that litigation may ensue and information is needed to advise the company's solicitors, and must be returned within 15 days of the accident without starting any repairs.

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Vishan ruggoo
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© © All Rights Reserved
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180 views2 pages

Mua Motor Vehicle Editable Claim Form April 2020

This is a motor insurance claim form requesting details about a vehicle accident, including information about the policyholder, drivers, vehicles involved, circumstances of the accident, damages, witnesses, and a declaration signed by the driver and policyholder. The form notes that litigation may ensue and information is needed to advise the company's solicitors, and must be returned within 15 days of the accident without starting any repairs.

Uploaded by

Vishan ruggoo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CLAIM FORM

MOTOR INSURANCE
Please return this form as soon as possible and in a maximum of 15 days from the date of accident. Do not start any repairs prior
to our official approval.
The information required in this form is sought in the bona fide belief that litigation may ensue and for the purpose of furnishing to the
solicitors of the Company information enabling them to advise us on behalf of the Insured.

Policy No : Period of insurance : From To

Terms of insurance : Insured value : Excess, if any :

INSURED
Name :

Address :

Telephone : (M) (O) (H)

Email address : Business Registration Number :

VEHICLE
Registration number : Make and Model :

Year : Type of Body :

DRIVER
Name :

Address : Date of birth :

Driving Experience : Years Months

Driving Licence No : Telephone :

Have you been prosecuted for any motoring offences? Yes No If so, when :

Are you in the Insured’s employment? Yes No If so, in what capacity and for how long?

If you are not the insured; what is your relationship with insured :

PURPOSE OF USE AT TIME OF ACCIDENT


For what purpose was the vehicle being used?

If used for the carriage of goods or passengers, please provide the following details:
Class of licence held : Usual capacity of the vehicle :
Load at time of accident :

PARTICULARS OF ACCIDENT
Date : Time : Place :

State of weather : What was the condition of the road?

Were any traffic lights in operation at scene of accident? If so, were they in your favour? Yes No

Was your vehicle on the main road? Yes No What was the approximate speed of your vehicle?

Has the driver been subject to any alcohol or drugs test (either blood, urine or breath) in connection with the accident?   Yes No
If yes, please give details

 4 Léoville L’Homme Street, Port-Louis, Mauritius


1
The Mauritius Union Assurance Cy. Ltd BRN C07000714T 230 207 5500 mua.mu
PARTICULARS OF ACCIDENT continued
Was an Agreed Statement of Facts completed after the accident? Yes No

Taking into account the circumstances of the accident, do you believe you are at fault? Yes No

If the accident was reported to the Police, please state which Police Station :

Please give full description of the accident and events leading up to the accident : DIAGRAM OF SCENE OF ACCIDENT

Please provide a SKETCH showing by arrows the respective directions


of vehicles and/or persons involved in the accident and indicate the
position of any nearby pedestrian crossing and/or traffic signs

DAMAGE TO INSURED VEHICLE


If your vehicle has been damaged, please provide details of the visible damage:

From which garage have you requested an estimate of repairs?

DETAILS OF THIRD PARTY


Name :

Address :

Telephone : (M) (H)

Insurer’s Name : Vehicle registration number :

Make and Model : For what purpose was the vehicle being used?

Please provide details of the visible damage on the third party vehicle :

WITNESSES OF ACCIDENT
Please state full names and contact details of persons who were travelling in your vehicle at time of accident :
(Name/Phone numbers/Email address)

Independent witness :

If any person received treatment at the scene of the accident or was taken to the hospital, please provide the names and contact
details of the injured persons, of the attending doctor, and the hospital.

DECLARATION
I/We hereby declare that the above statements and facts are true and that I/We have not withheld from the Company any information
which is to my/our knowledge connected with the accident.
Date: Driver’s Signature:

Date: Insured’s Signature:


Motor Insurance Claim Form 2

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