VEHICLE ACCIDENT REPORT FORM
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1 GENERAL ALLIANCE INSURANCE LIMITED Alliance House, Corner Sharpe Road & Independence Drive P.O. Box 1811, Blantyre, Malawi. Central Africa Tel: / 111 Fax: info@generalalliancemw.com VEHICLE ACCIDENT REPORT FORM The issue of this form does not imply admission of liability on the part of this company. All questions must be answered fully. Agency: Policy No. Claim No. Name of Insured: Full Address: Occupation: Tel No. PARTICULARS OF DRIVER Name of driver at time of incident: Address of driver: Driver s date of birth: 1. Is the driver: The owner? The owner s Employee (Tick as appropriate) (c) A friend or relative of the owner? 2. If 1 or (c), did you authorise the journey? If 1, how long have you employed him or her? (c) If 1 or (c), does the driver own a vehicle (i) If so, provide the name of the insurer of their vehicle YES / NO (c) YES / NO (i) VEHICLE ACCIDENT REPORT FORM 1/5
2 3. Has the driver got a full driving license? YES / NO If yes, provide details. (i) License No.: (ii) Date of issue: 4. When and where was the driver first licensed to drive? 5. Has driver ever been involved in an accident before? If so, give brief details and dates. PARTICULARS OF INSURED VEHICLE Registration Number Make of vehicle Body Type (Sedan, Lorry, etc.) Year of Make Horsepower or CC For what exact purpose was vehicle being used? (Full information) 1. If there is a hire purchase or other agreement, How much is outstanding? To whom is it owed? 2. If the vehicle was a motorcycle, Was a side car attached? Was there a pillion passenger? 1. Please provide details of the full extent of the damage to your vehicle. DAMAGE TO INSURED VEHICLE 2. Address where damaged vehicle can be seen. 3. Have you given instructions for repairs to be started? If yes, provide the estimated cost of repairs. 4. If tyre is damaged or stolen, please state make and mileage of tyre. VEHICLE ACCIDENT REPORT FORM 2/5
3 INJURIES TO OCCUPANTS OF INSURED VEHICLE 3. Was any injury sustained by the driver or passengers in your vehicle? If so, give details. 4. Are any of the passengers in your employ? PARTICULARS OF OTHER PARTY OR OWNER OF PROPERTY INVOLVED IN ACCIDENT Name: Registration No. Of other vehicle: Full Address: Name of other insurers: 1. Full extent of personal injuries and or damage to property 2. Has notice of any claim been given to you? Please send to the Company at once and unanswered, any written communication you may have received. CIRCUMSTANCES OF ACCIDENT, LOSS OR DAMAGE 1. Date of occurrence: Time of occurrence: (c) Place of occurrence: (c) 2. Which of your lights were on? 3. What was your speed? VEHICLE ACCIDENT REPORT FORM 3/5
4 4. Give full description of how the accident, loss or damage occurred: SKETCH 5. Please make a rough sketch of road widths and positioning of vehicles indicating how far vehicles were from the side of the road. VEHICLE ACCIDENT REPORT FORM 4/5
5 WITNESSES 1. Please state the names and addresses of your passengers: 2. Please state the names and addresses of other witnesses: 3. Was any statement as to fault made by witnesses or drivers at the time? If so give details: 4. To which police station was the occurrence reported? Date of report: DECLARATION I/We declare that, to the best of my/our knowledge and belief, these statements are true: Signature of Insured: Date: VEHICLE ACCIDENT REPORT FORM 5/5
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