Initiate Claims

Car Theft/Accident Claims Form
Client Details

Vehicle Registration

Driver Details
Is Driving Licence in force ?If Yes, which category? 
Driver's License No.Has it been endorsed ? 
Date of IssueDate of Expiry 
Place of Issue   
Is it a Learner's Permit ?If Yes, Number 
Particulars of Theft / Fire Incident
Who discovered this loss   
No. of persons in insured vehicleNo. of persons in other vehicle 
Address of Police Report Station  
Full Statement of Theft/Fire Incident  
Damage to Insured Vehicle
Full details of damaged Parts  
Present Vehicle Location   
Rough Estimate of Repairs   
Repairer's Name  
Repairer's Full Address  
Inventory of damaged parts  
Third Parties involved in the Accident
Type of property/Injury   
If Vehicle, Make  
Registration No  
Year of Make  
Present Location of Vehicle   
Is Owner insured ?   
If Yes, Policy No   
Name of Insurer   
Address of Insurer   
Upload Picture Evidences
Note: You can select multiple pictures to upload (MAX OF 2). Select both images at the same time by holding down the SHIFT KEY or you can add them one after the other.
 DECLARATION - I/We declare the foregoing particulars to be true and I/We authorize EQUITY ASSURANCE PLC (EAI) and/or their Legal representatives to deal with all matters arising from this accident at their discretion and if they deem it expedient to admit liability and/or negligence on the part of myself/our servants or Agents
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