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SUBMIT YOUR CLAIMS HERE

1Your details

2Claim Details

3Summary

PARTICULARS OF CLAIM

Please fill-in Claimant details

First Name:
Last Name:
Telephone:
Occupation:
Policy No:
E-mail Address:
Address:
Attach copy of covernote.

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Maximum file size: 2MB

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Please fill-in your details

MOTOR VEHICLE

Make:
Type:
Sum insured:
Year of
Manufacture:
Registration
No:
Purpose for which it was being used at the time of accident.
Attach copy of white book.

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Maximum file size: 2MB

DRIVER OF MOTOR VEHICLE

First Name:
Last Name:
Age:
License No.:
Address:
Driving Licence
No:
Date of issue:
Groups
Covered:
Vehicle:
How long has (s)He been driving?
Give full details of all driving convictions and endorsements of Licence.
Has (s)he been concerned in any previous accidents, if so, give details.
Attach copy of driver’s license.

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Maximum file size: 2MB

PARTICULARS OF DAMAGE

Date:
Time:
Place:
State weather and light at time of accident:
Speed of Vehicle:
Km per hour:
Type of road
Surface:
Explain briefly how the breakage happened:
Attach copy of police report.

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Maximum file size: 2MB

DAMAGE OWN VEHICLE

State extent of Damage:
Where can the vehicle be inspected?
Estimated Cost of Repairs:
Was the glass or surround damaged or weakened in any way before this incident?:
Attach copy of quotation.

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Maximum file size: 2MB

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CLAIMENT DETAILS

First Name:
Last Name:
Telephone:
Occupation:
Policy No:
E-mail Address:
Address:

MOTOR VEHICLE

Make:
Type:
Sum insured:
Year of
Manufacture:
Registration
No:
Purpose for which it was being used at the time of accident.

DRIVER OF MOTOR VEHICLE

First Name:
Last Name:
Age:
License No.:
Address:
Driving Licence
No:
Date of issue:
Groups
Covered:
Vehicle:
How long has (s)He been driving?
Give full details of all driving convictions and endorsements of Licence.
Has (s)he been concerned in any previous accidents, if so, give details.

PARTICULARS OF DAMAGE

Date:
Time:
Place:
State weather and light at time of accident:
Speed of Vehicle:
Km per hour:
Type of road
Surface:
Explain briefly how the breakage happened:

DAMAGE OWN VEHICLE

State extent of Damage:
Where can the vehicle be inspected?
Estimated Cost of Repairs:
Was the glass or surround damaged or weakened in any way before this incident?:

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