MOTOR ACCIDENT & THEFT CLAIM FORM
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1 MOTOR ACCIDENT & THEFT CLAIM FORM Please do not obtain any quotations. We will appoint an Assessor to assess the damage to your vehicle. Clear copy of Driver s licence to be submitted with claim form. Insured Policy No. of insured (cellphone) (business) Occupation Vehicle Make Model Odometer Reading Engine No Value Tare Gross Vehicle Mass Registration No VIN No Date of purchase Purchase price R If vehicle is subject to a Hire Purchase, Credit or Leasing Agreement, state name and address of Finance Company: Damage Damage to own vehicle Driver Full Foreign National - if yes : Date SA residency obtained - if yes : Do you have SA residency? (cellphone) State fully the purpose for which the vehicle was being used MUA Insurance Acceptances (Pty) Ltd (Registration number 2008/011925/07) is an authorised Financial Services Provider (FSP No.: 37947) underwriting on behalf of Auto & General Insurance Company Limited (Registration number 1973/016880/06), an authorised Financial Services Provider (FSP No.: 16354) info@mua.co.za WEB
2 Driver Was the vehicle being used with your permission? Was the driver in your employ? Has the driver any motor insurance? If YES, please state Policy No Insurer Details of any convictions for motoring offences Has licence been endorsed? Does the driver have any physical defects? Details of previous accidents Advanced Driving Course? (If yes please attach certificate) Passengers details (in insured vehicle) 1. and surname Injury 2. and surname Injury 3. and surname Injury 4. and surname Injury For what reason were they being transported? Are they employees? Other party details Damage to other vehicle Motor Accident & Theft Claim Form 2018 version 1 2
3 Other party details Damage to property other than vehicles Personal Injuries (other than in Insured vehicles) Motor Accident & Theft Claim Form 2018 version 1 3
4 Witness Theft Was vehicle locked? Who has the keys? Police station Colour Police Case number Chassis number Details of accessories stolen Anti-theft device? Incident details Date Time Province Intersection Speed before accident Weather conditions Road surface Which vehicle lights were on? Suburb Speed on impact Visibility Width of road Street lighting Was any warning, e.g. hooting, indication etc. given by you? Police Case No. Was the driver tested for alcohol or drugs? Police station Result of test Description of accident (include intersection) Motor Accident & Theft Claim Form 2018 version 1 4
5 Incident details Sketch of Accident (if necessary, please use a separate page). Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety or warning signs in the vicinity of the scene of accident. Declaration Information Sharing Declaration It is necessary for insurance companies to share information in order to underwrite (assess and price the risks) policies fairly and lower the number of fraudulent claims. In view of the above, I/we (and any person representing me) declare by the submission and/or signing of this document to accept that it is in the public interest for insurers to share insurance information (including credit information); consent to my policy, claims or credit information being verified or shared with third parties in the ordinary course of business; accept that any information provided to the insurer may be stored in a shared database; consent to such information being given to any other insurance company and/or reinsurance company or its agent should there be a legitimate business reason for doing so; accept that this information may be checked against other legal sources or databases; and confirm that all information provided is true, correct and complete. I/We understand that the completion of this form does not bind the Company to payment of any claim. I/We further declare that the foregoing particulars are true in every respect and that I/we have not withheld from the Company any information connected with the loss: Signature of driver Date Signature of insured Date Capacity NB. It is important that you notify Insurers immediately you become aware of any impending prosecution, inquest or demand Motor Accident & Theft Claim Form 2018 version 1 5
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