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    Trident Claim Form

    Uploaded by

    zemmy
    The document is a motor claim form for an insured seeking compensation for damages to their vehicle from an accident. It requests details about the insured, their driver, the accident itself including date, location, cause, injuries and damages. It asks for information on witnesses, police reports, and any other involved vehicles or parties. The form aims to gather all relevant facts about the incident to facilitate processing and settlement of the insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Trident Claim Form

    Uploaded by

    zemmy
    121 views5 pages
    The document is a motor claim form for an insured seeking compensation for damages to their vehicle from an accident. It requests details about the insured, their driver, the accident itself including date, location, cause, injuries and damages. It asks for information on witnesses, police reports, and any other involved vehicles or parties. The form aims to gather all relevant facts about the incident to facilitate processing and settlement of the insurance claim.

    Original Description:

    trident Claim Form

    Original Title

    trident Claim Form (8)

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    The document is a motor claim form for an insured seeking compensation for damages to their vehicle from an accident. It requests details about the insured, their driver, the accident itself including date, location, cause, injuries and damages. It asks for information on witnesses, police reports, and any other involved vehicles or parties. The form aims to gather all relevant facts about the incident to facilitate processing and settlement of the insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    121 views5 pages

    Trident Claim Form

    Uploaded by

    zemmy
    The document is a motor claim form for an insured seeking compensation for damages to their vehicle from an accident. It requests details about the insured, their driver, the accident itself including date, location, cause, injuries and damages. It asks for information on witnesses, police reports, and any other involved vehicles or parties. The form aims to gather all relevant facts about the incident to facilitate processing and settlement of the insurance claim.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    MOTOR CLAIM

    MOTOR CLAIM FORM


    1st FLOOR, CAPITOL HILL TOWERS, CATHEDRAL ROAD P. 0. BOX 55651-00200,
    NAIROBI TEL: (254 - 20) 2721710 FAX: (254 - 20) 2726234 E-mail: info@trident.co.ke
    ___________________________________________________________________________________________________________
    MOTOR CLAIM FORM
    The issue of this form is not to be taken as an admission of liability.
    Please in no case aamit your fault nor make any payment or offer of payment without the written authority of the Company.
    Answer ALL questions FULLY. It will avoid unnecessary correspondence and consequent delay in the settlement of the claim.

    1. Name of Insured ____________________________________ Policy No. __________________________________________


    (in full)
    2. Address ___________________________________________ P.O.Box No.______________ __________________________
    (Plot No.-Street Name)
    3. Occupation _________________________________________ Telephone No. _______________________________________

    4. Have you paid premium under this policy:____________________________________________________________________

    5. The Insured Vehicle:


    (a) Make _________________________________ (b) Registration No. __________________________________________
    (c) State purpose for which it was being used at the time of accident ____________________________________________
    (d) Was the vehicle being used with your knowledge and consent ______________________________________________
    (e) If the claim is in respect of motor cycle, state whether a Pillion Passenger was being carried at the time of accident__
    (f) If the claim is in respect of a lorry, state:-
    1. Whether a trailer was hauled _________________________________________________________________
    2. The nature of goods carried at the time of accident ________________________________________________
    3. The weight of the load carried at the time of accident _______________________________________________
    4. Name of the owner of goods __________________________________________________________________
    (g) Is the vehicle your own property? _________________________________________________________________
    If not, who else is interested in this vehicle and how? __________________________________________________

    6. The person driving at the time of accident:


    (a) Full name of the person ____________________________________________________________________________
    (b) Address ________________________________________________________________________________________
    Relation to Insured ________________________________________________________________________________
    (c) Particulars of Driving License:
    1. License No. ____________________________ 2. Date and Place of Issue ________________________________
    3. Renewal No. ____________________________ 4. Valid up to ___________________________________________
    5. Type of License __________________________ 6. Age of the Driver _______________________________________
    (d) Is he your permanent paid driver? If so, since when? _____________________________________________________
    (e) Has Driver's License ever been endorsed or suspended? __________________________________________________
    If so, give full details with dates _____________________________________________________________________
    (f) State whether:
    (1) The driver has ever been prosecuted for driving offences _______________________________________________
    If so, give details _________________________________________________________________________________
    (2) The driver has been involved in any accidents previously ______________________________________________
    If so, give details _________________________________________________________________________________
    (3) The driver has ever been refused motor vehicle insurance or continuance thereof____________________________
    (4) How long has he been driving motor vehicles? ____________________________________________________
    (5) Has the driver any other insurance of his own? (If so, name of the insurers and details of the vehicle):

    (6) Was he sober ____________________________


    IMPORTANT: Kindly attach a copy of driver's license
    7. The Accident (Damage, Fire, Theft):

    (a) Date of Occurrence _____________________________ (b) Time __________________________________________

    (c) Place (Street or Road and Town) ________ . ________________ : _____________________________________________

    (d) Were you in the Vehicle? ______________________________________________________________________________

    (e) If not, when was it reported to you? ______________________________________________________________________

    (f) On what side of the Street or Road was your vehicle and how far from the kerb? ___________________________________

    (g) What was the width of the Street or Road? _________________________________________________________________

    (h) And what speed was it being driven at the time of the Accident? _______________________

    (i) In case of theft please state:

    (1) Was the vehicle properly locked? __________________________

    (2) Is it fitted with any anti-theft devices such as burglary alarms, steering lock, etc.?___________________________________

    If so, give details of such devices __________________________________________________________________________

    (j) Please give full details of the nature and cause of the Accident/Theft/Fire:

    (k) Please draw a rough sketch plan of the scene of the accident and attach.
    8. The Damage: TO THE INSURED VEHICLE

    (a) Give in detail the extent of all damage to the insured vehicle directly due to the accident:

    (b) Estimated cost of repairs K.Shs. ______________________________________________________________________

    (c) Where can the vehicle be inspected? __________________________________________________________________

    N.B. - If possible, an estimate of repairs should be attached to this form and in any event it must be sent to the Company without undue
    delay
    ___________________________________________________________________________________________________________
    _

    9. Other Vehicle(s) Involved in the Accident ____________________________________________________________________

    Make and Registration No.______________________________________________________________________________

    Insurance Company and Policy No. _______________________________________________________________________

    Name and Address of Owner _____________ _______________________________________________________________

    Name and Address of Person Driving _____________________________________________________________________

    Details and Extent of Damage to Third Party Vehicle __________________________________________________________

    10. Death or Injury to Persons

    (a) Has the accident caused any injury to any person or persons? _________________________________________________
    Name Address Occupation Nature of injuries Whether being conveyed in the
    If so, give me the following particulars
    vehicle or not

    (b) If any person has been removed to a Hospital or medically attended, give name and address of Hospital or Doctor

    (c) Did the accident cause damage to property or livestock? If so, name and address of the owner stating nature and extent of
    damage.
    (d) Has any claim been made upon you by any Third Party? If so, give details and attach the intimation:

    (e) If accident was caused by the fault of any Third Party, give name and address of such person/s:

    (f) How many persons were in the Vehicle at the time of accident? _______________________________________________

    (g) Give the following particulars about all the witnesses to the accident

    Name Address Whether being conveyed in the


    vehicle or not

    (e) Was the matter reported to the Police? If so, give name of Police Station and date: ___________________________________

    _____________________________________________ Ref No. (If available) __________________________________________

    (f) What action, if any has been or is being taken by the Police or any other authority?____________________________________

    (g) Give particulars of other insurance on the Vehicle, if any ________________________________________________________

    (h) Whether you have ever before lodged a claim under this Policy and/or any Motor Vehicle Policy? ________________________

    If so, give particulars ___________________________________________

    I/We the above named do hereby, to the best of my/our knowledge and belief, warrant the truth of the foregoing statements in every
    respect and l/we agree that if l/we have made, or in any further declaration the Company require in respect of the said accident, shall
    make any false or fraudulent statement, or any suppression or concealment the Policy shall be void and all rights to recover thereunder
    in respect of past or future accidents shall be forfeited.

    Date _______________________ 20 ___________

    Full Name_____________________________________________ ____________________________________________


    (Signature of the Insured) Where
    necessary, the Insured's official stamp
    must be used.

    Note: ANY NOTICE, WRIT OR SUMMONS RECEIVED FROM THE THIRD PARTY MUST BE IMMIDIATELY
    COMMUNICATED TO THE COMPANY ATTHE FOREGOING ADDRESS.

    4 TIC/MCF/UKU02-10

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