MOTOR CLAIM FORM Insurers - MUNICIPAL (ZM) POLICY NO NHE-15CA02-0013 – This form must be completed and full and returned to the Insurance Office as soon as possible after the incident. Insurance Office, , Charles Stewart House, e-mail : telephone : 0131 650 9154 DEPARTMENT NAME, ADDRESS AND CONTACT NO : Vehicle Registration Number Make & Model DRIVER |(or person last in charge of the vehicle, prior to the damage occurring) Name : Date of Birth : Address : Occupation : Full/Provisional licence? Licence No. Any convictions or prosecutions pending ? Y/N DAMAGE TO UoE VEHICLE Please provide full details of damage – Description Is vehicle in use? YES/NO Where can it be inspected : DETAILS OF ACCIDENT Please provide full details – Date Time Location Speed of vehicle Before accident At time of impact Lights displayed on Your vehicle Other vehicle Warning given by Your vehicle Other vehicle Condition of road Weather Conditions Did police officer take YES/NO If yes, please provide details? number and station Please give full details of accident
MOTOR CLAIM FORM Insurers - MUNICIPAL (ZM) – POLICY NO NHE-15CA02-0013 This form must be completed and full and returned to the Insurance Office as soon as possible after the incident. Insurance Office, , Charles Stewart House, e-mail : telephone : 0131 650 9154 DEPARTMENT NAME, ADDRESS AND CONTACT NO : Vehicle Registration Number Make & Model DRIVER |(or person last in charge of the vehicle, prior to the damage occurring) Name : Address : Date of Birth : Occupation : Full/Provisional licence? Y/N Licence No. Any convictions or prosecutions pending ? DAMAGE TO UoE VEHICLE – Please provide full details of damage Description Is vehicle in use? YES/NO Where can it be inspected : DETAILS OF ACCIDENT – Please provide full details Date Time Location Speed of vehicle Before accident At time of impact Lights displayed on Your vehicle Other vehicle Warning given by Your vehicle Other vehicle Condition of road Weather Conditions Did police officer take details? YES/NO If yes, please provide number and station Please give full details of accident
Accident-reporting-procedure-and-claim-form(2).docx