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 
Period   
     
Particulars of Theft / Fire Incident
Who discovered this loss   
DateTime 
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
Fullname  
Address   
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
Removed
   
  
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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