Please enable JavaScript in your browser to complete this form.1Customer Details2Statement by ClaimantPolicy Number *Title *Mr.Mrs.MissDr.Hon.Full Name *FirstMiddleLastEmail Address *Phone NumberAddress *Address Line 1Address Line 2CityState / Province / RegionNext1. (a) When did the accident occur? *1. (b) Where did the accident occur? *1. (c) Explain fully how the accident happened. *2. Give names and addresses of witnesses (if any)3. (a) Was the accident reported to Police? *YesNo3. (b) (i) Name of the Police Station3. (b) (ii) Date of Notification3. (b) (iii) Name of person who notified the police.4. (a) Were persons injured? *YesNo4. (b) Provide full detailsInclude the following details: i. Name | ii. Occupation | iii. Age | iv. Nature of injury | v. Full Address5. (a) Was any property damaged? *YesNo5. (b) Provide full detailsInclude the following details: i. Quantity | ii. Description of property | iii. Extent of damage | iv. Owner’s Name & Address6. (a) Have you received notice of a claim? *YesNo6. (b) (i) Provide full details6. (b) (ii) attach to this form any correspondence received. Click or drag files to this area to upload. You can upload up to 10 files. 7. (a) Have you admitted liability? *YesNo7. (b) Do you think you are legally liable? *YesNo7. (c) Give reasons why you are legally liable. 8. (a) Are there any other insurances covering this accident? *YesNo 8. (b) Give name of Insurance Company DECLARATIONI / We hereby declare that all statements on this form are in all respects true and correct.Date *EmailSubmit
