Scribd
Upload
6 views4 pages

Motor Accident Report Form-2023 Kyc (3)

The document is a Motor Accident Report Form for policyholders of Enterprise Insurance in Ghana, outlining the necessary information and documentation required to process a claim following a motor vehicle accident. It emphasizes the importance of accuracy in the information provided and advises against admitting liability or making payments without consulting the insurance company. The form includes sections for details about the insured, vehicle, accident circumstances, third parties involved, and required documentation for claim assessment.

Uploaded by

nanakofioppongantwi2012
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
6 views4 pages

Motor Accident Report Form-2023 Kyc (3)

The document is a Motor Accident Report Form for policyholders of Enterprise Insurance in Ghana, outlining the necessary information and documentation required to process a claim following a motor vehicle accident. It emphasizes the importance of accuracy in the information provided and advises against admitting liability or making payments without consulting the insurance company. The form includes sections for details about the insured, vehicle, accident circumstances, third parties involved, and required documentation for claim assessment.

Uploaded by

nanakofioppongantwi2012
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
You are on page 1/ 4

Advantage Place

Mayor Road
Ridge West
Accra Ghana

T: 0302 634777,
M: 0548 231149
E:claims.insurance@enterprisegroup.com.gh

www.myenterprisegroup.io

MOTOR ACCIDENT REPORT FORM


Notice to Policyholders:

Our solicitors have advised that in the event of an injury to a Third Party or damage to his property, you
should supply the information set out below so as to enable us and our Solicitors to give advice thereon
and conduct any litigation which may ensue.

It is necessary that great care should be taken in completing this form and the information given therein
should be strictly accurate, irrespective of whether it is in your favour or otherwise. You should not make
any payment, offer or promise of any payment or admit liability in anyway, as by so doing you may
prejudice your position and make settlement a difficult matter.
AKOSUA ANSAH-ANTWI
MANAGING DIRECTOR

POLICY No………………………...............
RENEWAL DATE………………..………..

Name of Insured........………………………………………………………………………... Gender M / F


Mobile No ……………………………………………… Email………………………..…………………..
Postal Address ………………………………………….. Ghana Post Address …………..………….…….
Occupation……………………………………………… Date of Birth ……………………….…….…….
To enable us process the claim kindly submit the following:
• Individual/Retail Clients: copy of insured’s Ghana Card (i.e. ECOWAS Identity Card)
• Corporate Clients: Tax Identification No (TIN) _____________________________

PARTICULARS OF MOTOR VEHICLE CONCERNED:

Registration No. ..…………...… Make …………….. Model…………… Year of Make……………….


Is the vehicle the subject of a hire purchase or loan agreement? Yes / No
If so state name of finance company or lending organisation……………………………………………….
………………………………………………………………………………………………………………
If claim is under a Motor Trade Policy give name and address of owner of vehicle……………………….
………………………………………………………………………………………………………………
State fully the purpose for which the vehicle was being used at the time of accident. (It is not sufficient
to state “Business” or “Private”) ………………………………………………...………………………
Was the vehicle being used with your consent? Yes / No
PARTICULARS FOR PERSON DRIVING AT THE TIME OF ACCIDENT:
Full Name ……………………………………….………… Address ………...…………………………..
Age …………….… Occupation ………………..…………….. Telephone No. ...…..…...……………….
Driving Licence No. ……………………………….… Date of Issue: ….……………...…………....…….
For what group of vehicle has the licence been issued: ………………………………...…………………..
Has the driver ever been convicted of any motoring offence? Yes / No.
If so give details: ……………………………………………………………………………………………
State whether the person driving at the time of accident was: (a) The Owner
(B) An employee (c) Relative or friend? ......……………………………………………………
If an employee, how long has he been in your employment as a driver? …………………………………..
If owner was not driving, state whether the person driving owns a vehicle himself? Yes / No.
If so state name and address of the Insurer of the person driving and number of Policy held by him/her
………………………………………………………………………………………………………………

CIRCUMSTANCES OF ACCIDENT:
Date of incident: …………………………, 20………… Time of incident: .……………… a.m./p.m.
Exact location of incident: ………………………..….……………………………………………………..
Speed of vehicle: ……………....………………………………..……………………………….………....
If after lighting up time, what lights lit on your vehicle? .………………...………..………………..…......
How may persons were in your vehicle at the time of the accident? ……………..………………….……..
If you were not in the vehicle, when was accident reported to you? ….…..………………………………..
Give full description of how the accident happened: ….…………………………...………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
(Use reverse of form if more space is required)

In your opinion was the accident caused by your driver? If not, by whom? …………………….…...........
Damage to your vehicle ………………………………………………………………………..……….....
………………………………………………………………………………………………………………
………………………………………………………………………………………………………………
Where can the vehicle be seen? .....................................................................................................................
Name and address of nearest repairers: …………………………………….…………………………........

THIRD PARTIES INVOLVED IN ACCIDENT:


Name and address of persons injured and the extent of their injuries:
Injured person in your vehicle: …………………………………………………………………………..
1. …………………………………………………… 2. …….………………………………………….…
3. …………………………………………...………. 4. ………….…………………………………….…
Injured persons in the other vehicle ...………………………..…………………..……………………..
1. …………………………………………………… 2. …….………………………………………….…
3. …………………………………………...………. 4. ………….…………………………………….…
Injured Pedestrians:…....…………………………………………………………………………………
………………………………………………………………………………………………………………
State details of other vehicle involved : Regd. No. …………………..…..….. Make …………..…….…
Model: …………………………………………………………………..…………………………………..
Driver Owner
Name …………………………………….. …………………………………………..
Phone Number …………………………………….. …………………………………………..
Office Address …………………………………….. …………………………………………..
Residential Address …………………………………….. …………………………………………..
State name and address of Insurer of this vehicle and policy number ……………....…………………….
………………………………………………………………………………………………………………
Details of damage to this vehicle: ………………………...…………………..……………..…………….
Have any claims been made against you? Yes/No If so, state particulars below and note that any letter or
communication received by you must be forwarded immediately unanswered, to this Company
………………………………………………………………………………………………………………
Has any person involved in the accident been given notice of intended prosecution by the Police? Yes/No If
so, state details .…...………………………………………………………………………………………….....
Witnesses:
1. ……………………………………………………………………………………...………………….…
2. ……………………………………………………………………………………...………………….…
3. ……………………………………………………………………………………...………………….…

Was the accident reported to the Police? Yes/No. If so, state date reported and at which police station
………………………………………………………………………………………………………………
Name of Police Officer who took particulars: …………………….……………………………………..
Do you hold more than one policy indemnifying you in respect of this accident? Yes/No.
I/We declare that the above statement is true in all respects to the best of my/our knowledge and belief
and I/We hereby leave in the hands of the Company in accordance with the Conditions of the Policy the
conduct of all claims, and litigation arising out of this accident and to which the Policy applies, to deal
with, to prosecute and /or settle as they think fit without further reference to me/us and I/We undertake
to give all such information and assistance as the Company may require.

Date: …………………………… Signature of Policy Holder: ……………….……..…………..…

The Company does not admit liability by the issue of this form.
SKETCH
Please make a sketch showing position of vehicles and persons concerned both before and after
the accident, and showing the direction in which they were travelling.

POSITION BEFORE ACCIDENT

POSITION AFTER ACCIDENT

CHECKLIST OF DOCUMENTATION REQUIRED FOR CLAIM ASSESSMENT


Below is a list of minimum documentation required to process your claim. In certain circumstances additional
information may be required in order for further confirmation. Please tick against the documents you have submitted:

 Completed Claim Form  Estimate of Repairs


 Copy of Ghana Card (Retail/Individual Clients  Pictures of Damaged vehicle (s)
 Tax Identification No (TIN) (Corporate Clients)  Police Report (Theft, Injury)
 Driver’s Licence (Person driving when accident  Medical Receipts/Prescriptions (Injury)
occurred)  Fire Service Report (Fire)

For Enterprise Insurance Staff Only


OFFICIAL VALIDATION

I, ………………………………………………………….……, of ………………………….....…. branch


acknowledge receipt of this form and verify that it has been properly and duly completed.

……………….……..…………..… ……………….……..
Signature Date

You might also like

pFad - Phonifier reborn

Pfad - The Proxy pFad of © 2024 Garber Painting. All rights reserved.

Note: This service is not intended for secure transactions such as banking, social media, email, or purchasing. Use at your own risk. We assume no liability whatsoever for broken pages.


Alternative Proxies:

Alternative Proxy

pFad Proxy

pFad v3 Proxy

pFad v4 Proxy