Claims

Motor Vehicle Personal Accident Burglary Goods-In-Transit Fire/ Special Peril Marine Vessel Marine Cargo Hull Risk Fidelity Guarantee Contract Work

Vehicle Claim

Policy No

Insured’s Phone No

First Name

Last Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Occupation

INSURED’S VEHICLE INVOLVED IN THE ACCIDENT

Make

Year of Make

Registration Number

Engine Number

Chassis Number

Purpose for which vehicle was being used

DRIVER at time of accident

First Name

Last Name

Age

Category of Driving Licence

Expiry date of licence

He/She has been driving (a) this type of vehicle since

Any other type

When was he/she previously convicted of driving offence?

State whether the person driving at the time of accident if

If employee how long in service?

CIRCUMSTANCES OF ACCIDENT

Date

Time

Was the vehicle in use with the Insured’s permission or authority?

Exact location of accident

Road condition and weather

Estimated speed of your vehicle

Who was at fault?

Describe the accident

WITNESSES

If no name of witness, please state reason

Police or other authority (state officials no.)

If no police witness, to which station did you report?

DAMAGE TO INSURED’S VEHICLE

State full details of damage

Where can the vehicle be inspected?

Name & Phone no of person to be contacted:

Where the Policy provides cover for damage to the insured’s vehicle a detailed repair estimate should be submitted as soon possible but repairs should not be done without the approval of the Company unless within the limit permitted by the Policy

State names and addresses of all passengers and/or other persons sustaining injury, nature of injury and where exactly they were at the time of the accident

The Details of the Third Party Vehicle

Make of the Vehicle

Registration Number

Year of make

Engine Number

Chassis Number

Purpose for which vehicle was being used

Give name, phone No., email address and address of owner and registered number of the owner of the third party vehicle(s) involved :

Give particulars of any damage sustained by such vehicle or any property not belonging to you

If notice of Third Party claim has been given, verbally or in writing, please give particulars

If any written communication is received please forward it immediately unanswered

If the current premium has been paid please state

Amount NGN

Receipt Number

Date of Receipt

By submitting the form I/We declare that the foregoing particulars are true in every respect and I hereby permit the company in accordance with the Conditions of the Policy to conduct all claims and litigation arising out of this accident and to which the Policy applies, to deal with, to prosecute and/or settle as they think fit without further reference to me and I undertake to give all such information and assistance as the Company may require.

PERSONAL ACCIDENT CLAIM FORM

PERSONAL ACCIDENT CLAIM FORM

Please note that the issue of this form does not show acceptance of liability by insurer

Policy No.

Insured’s Phone No

The Insured

Name of Injured person

Age

Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Private Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

The accident happened at/about - p.m. / a.m

The accident happened at/about - day/year

How did it happen and what were you doing at the time? Give full particulars

Date

Where

If goods were carried in your vehicle or vehicle operated by you, state Reg. No of Vehicle

If goods were carried in your vehicle or vehicle operated by you, state If goods were carried in your vehicle or vehicle operated by you, state Value of Load

If goods were carried in your vehicle or vehicle operated by you, state Make/Type of Vehicle

If goods were carried in your vehicle or vehicle operated by you, state If goods were carried in your vehicle or vehicle operated by you, Were all doors and windows secured?

If goods were carried in hired vehicle or vehicle not operated by you, state date of dispatch

If goods were carried in hired vehicle or vehicle not operated by you, state time of dispatch

If goods were carried in hired vehicle or vehicle not operated by you, state if any receipt was issued to you on delivery

If goods were carried in hired vehicle or vehicle not operated by you, state if any receipt was issued to you on collection

When did you notify the party responsible for transit of the loss/damage and how?

In respect of property lost, when did you notify the police?

what other step have you taken to trace it?

In respect of property damaged, where can it be inspected

Please give details of any other insurance covering this loss/damage (a) Name of insurer (b) Policy No

If all the property lost/damaged are not your own, give details of ownership or interest

Have you paid the current Insurance Premium?

To whom paid?

Amount NGN

Receipt No.

Date

Amount being claimed for

Statement of Claim

Remember to allow for age, use, wear and tear in the amount you are claiming

Property Description

Owner

Purchase Price

Amount Claimed

By submitting this form, I/We hereby declare that the property claimed for and particulars given above has been lost or damaged and that all statements on this form are, to the best of my/our knowledge and belief correct.

BURGLARY/THEFT CLAIM FORM

BURGLARY/THEFT CLAIM FORM

Policy No.

Insured’s Phone No

State full address of the Premises at which the loss was sustained

Address Line 1

Address Line 2

City

State

Zip Code

Country

When and by whom was it discovered and who witnessed the discovery?

When did the loss take place?

When was the Police informed and at which station?

Which rooms were rifled?

Which door(s) or window(s) were forced

Were the premises occupied at the time of the loss?

What date and time was it last occupied

Who do you suspect?

Who else has any interest of any kind in the property being claimed for

Which other current insurance covers this loss?

Please indicate the total value of the contents of the premises at the time of loss

If the contents of the premises are insured against fire state the amount insured and the name of the insurance company

Please state the dates and amounts of previous fire or burglary/theft

Premium paid for current period N

Receipt No

GOODS IN TRANSIT CLAIM FORM

GOODS IN TRANSIT CLAIM FORM

Policy No.

Insured’s Phone No

State full address of the Premises at which the loss was sustained

Address Line 1

Address Line 2

City

State

Zip Code

Country

What happened to the goods