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Motor Claim Form

Jubilee General Insurance Company Limited provides a motor vehicle claim form for policyholders to file a claim in the event of an accident or damage to their vehicle. The two page form requests details about the insured, policy, vehicle, accident/theft including date and time, description of the incident, speed, driver information, occupants, injuries, police report, responsibility, repairs and third party details if applicable. The insured must sign declaring the information provided is true and correct and authorizes the company to file a claim on their behalf against a third party if involved.

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muhammadmoazmaalik
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445 views2 pages

Motor Claim Form

Jubilee General Insurance Company Limited provides a motor vehicle claim form for policyholders to file a claim in the event of an accident or damage to their vehicle. The two page form requests details about the insured, policy, vehicle, accident/theft including date and time, description of the incident, speed, driver information, occupants, injuries, police report, responsibility, repairs and third party details if applicable. The insured must sign declaring the information provided is true and correct and authorizes the company to file a claim on their behalf against a third party if involved.

Uploaded by

muhammadmoazmaalik
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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Jubilee General Insurance Company Limited

(formerly New Jubilee Insurance Company Limited)


Jubilee Insurance House, I.I.Chundrigar Road, Karachi 74000
UAN: 111 654 111, Tel: (021) 32416022-26, Fax: (021) 32438738, 32416728
Email: info@jubileegeneral.com.pk, Website: www.jubileegeneral.com.pk

MOTOR VEHICLE CLAIM FORM


THIS FORM MUST BE RETURNED TO THE COMPANY IMMEDIATELY WITH ALL QUESTIONS FULLY ANSWERED.
(The company does not admit liability by the issue of this form).
In the event of accident or damage to your Vehicle it is advisable in your own interest to immediately report to the Police.

1. Name of Insured _________________________________________________________________________


2. Address________________________________________________________________________________
Telephone No. _____________________Cell No._______________________________________________
3. Policy No. ______________________________________________________________________________
4. Make of Vehicle ____________________ Model __________________ Registration No. ________________
Chassis No_________________________ Engine No.____________________________________________
5. State date and time at which accident /theft/snatching occurred ___________________________________
6. Please explain how the accident/theft/snatching took place and for what purpose was the Vehicle being
driven____________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
7. At what speed was the Vehicle being driven? __________________________________________________
8. Please state Driver’s Name ____________________ License No. _________________ Expiry Date _______
9. Was the driver, under the influence of alcohol or drug at the time of accident? ________________________
10. State names of all occupants of your Vehicle __________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
11. Was the driver or any other occupant of your Vehicle injured? If so give particulars ___________________
________________________________________________________________________________________
________________________________________________________________________________________
12. Has the accident been reported to Police? _________ Did a Police Officer take particulars? _____________
Did he witness the accident _______________________State Police Officer’s name __________________
Station to which attached ________________________________________________________________
13. State who in your opinion was to blame for accident and why ____________________________________
________________________________________________________________________________________
14. Name, address and occupation of such person responsible for accident _____________________________
________________________________________________________________________________________
15. Is Police action pending against any person as a result of the accident? ____________ If so against whom,
and what is the charge? __________________________________________________________________
16. State estimated cost of repairs in your opinion ________________________________________________
17. Where can the Vehicle be inspected and state your repairer _____________________________________

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IF THIRD PARTY HAS BEEN INJURED OR DAMAGE HAS BEEN CAUSED TO THE VEHICLE OR OTHER PROPERTY
OF THIRD PARTY, PLEASE ANSWER THE FOLLOWING ADDITIONAL QUESTIONS:-

1. Name & address of person injured or owner of other Vehicle or property damaged_____________________
________________________________________________________________________________________
2. Nature of bodily injury ____________________________________________________________________
3. Nature of damage to other Vehicle or property _________________________________________________
4. Make of other Vehicle ___________________________________ Registration No. ____________________
5. Has any claim been made against you? _______________________________________________________

Do not admit any liability in any circumstances. Immediately despatch to the Company unanswered, any
written communication which may have been received.

I/We Solemnly declare that to the best of my/our knowledge and belief foregoing particulars are
true and correct in every respect, and authorize you to lodge a claim on my/our behalf against the
third party (if any).

Date _______________ 20____

________________ ___________
Insured’s Signature Stamp

N.B. :- Use extra sheet for providing additional


information wherever necessary

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