THIRD PARTY DAMAGE TO VEHICLE/PROPERTY Please provide full details – Name, Address and Contact no of Driver/Owner Vehicle and Registration No. Insurer name, address and Policy Number Full Description of Damage to vehicle/property PERSONS INJURED Name and address (state whether driver, passenger or pedestrian) Details of Injury WITNESSES (GIVE FULL NAMES AND ADDRESSES) Independent Witnesses Passengers in the Insured vehicle Managers Comments Accident must be notified to Manager – Date : : Manager’s name DECLARATION MUST BE SIGNED BY DRIVER – I declared that to the best of my knowledge/belief, all information on this claim form is correct Name (signature) Date : Print Name Position / Contact No This section must be completed before the form is returned to the Insurance Office MANAGER’S COMMENTS – Comments Name (signature) Date : Print Name Position / Contact No
THIRD PARTY DAMAGE TO VEHICLE/PROPERTY – Please provide full details Name, Address and Contact no of Driver/Owner Vehicle and Registration No. Insurer name, address and Policy Number Full Description of Damage to vehicle/property PERSONS INJURED Name and address (state whether driver, passenger or pedestrian) Details of Injury WITNESSES (GIVE FULL NAMES AND ADDRESSES) Independent Witnesses Passengers in the Insured vehicle Managers Comments – Accident must be notified to Manager Date : Manager’s name : DECLARATION – MUST BE SIGNED BY DRIVER I declared that to the best of my knowledge/belief, all information on this claim form is correct Name (signature) Print Name Date : Position / Contact No MANAGER’S COMMENTS – This section must be completed before the form is returned to the Insurance Office Comments Name (signature) Print Name Date : Position / Contact No
Accident-reporting-procedure-and-claim-form(2).docx