Motor Vehicle Accident Claim – Westwood Insurance Brokers

Policy Number

Name *

First

Last

Contact Number *

Identity Number / Company No. *

Occupation

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Vehicle Details

Registration Number *

Make

Model

VIN

Odometer Reading

Name of Finance Company

In whose name is the vehicle registered?

Damage

Repairer's Name

Repairer's Contact Number

Repair Estimate

e.g. R10 000

Where Can Your Damage Be Inspected

Current Location of the Vehicle

Damage to own Vehicle

Attach Quotations

Click or drag files to this area to upload. You can upload up to 3 files.

Driver Details

Was The Driver The Insured? *

Name of Driver *

First

Last

Contact Number of Driver

Identity Number *

Driver's License Number *

Residential Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

State Fully The Purpose For Which The Vehicle Was Being Used *

Was He or She Driving With Your Permission? *

Were He/She in Your Employ? *

Do They Have Any Motor Insurance? *

State Policy Number

Company Name *

Eg. Hollard

Details of Any Convictions For Motoring Offences *

Has License Ever Been endorsed *

Do They Have Any Physical Defects?

Details of Previous Accidents *

Passengers In Insured Vehicle

Were there any passengers in the vehicle? *

Number of Passengers Carried *

Passenger 1 Name

First

Last

Contact Number

Passenger 1 Injuries

Passenger 2 Name

First

Last

Contact Number

Passenger 2 Injuries

Passenger 3 Name

First

Last

Contact Number

Passenger 3 Injuries

Passenger 4 Name

First

Last

Contact Number

Passenger 4 Injuries

Passenger 5 Name

First

Last

Contact Number

Passenger 5 Injuries

For What Purpose Were They Carried *

Are Any of Them Your Employees?

Other Parties

Number Of Injuries Other Than Insured Vehicle *

Name Of Person 1 *

First

Last

Contact Number *

Relationship To Accident

Eg. Driver, Passenger

Injuries

Name Of Person 2 *

First

Last

Contact Number *

Relationship To Accident

Eg. Driver, Passenger

Injuries

Name Of Person 3 *

First

Last

Contact Number *

Relationship To Accident

Eg. Driver, Passenger

Injuries

Name Of Person 4 *

First

Last

Contact Number *

Relationship To Accident

Eg. Driver, Passenger

Injuries

Other Party Vehicles

Number of Vehicles Involved *

Vehicle 1 Registration Number

Make

Eg. BMW, Ford

Name of Owner

First

Last

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact Number

Details Of Damage *

Vehicle 2 Registration Number *

Make *

Eg. BMW, Ford

Name of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact Number *

Details Of Damage *

Vehicle 3 Registration Number

Make *

Eg. BMW, Ford

Name Of Owner *

First

Last

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Contact Number *

Details Of Damage *

Other Party Property

Number of Damaged Property

Name Of Owner 1

First

Last

Contact Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Details Of Damage

Name Of Owner 2

First

Last

Contact Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Details Of Damage

Name Of Owner 3

First

Last

Contact Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Details Of Damage

Witnesses

Number Of Witnesses *

If there were more than 2, please list the most pertinent 2 witnesses.

Name Of Witness 1

First

Last

Contact Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Name Of Witness 2

First

Last

Contact Number

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Accident Details

Date of Accident

Location of Accident

Time of Accident

Speed Before Accident

Speed at Moment of Accident

Was Any Warning Given To You

Eg. Hooting, Indicators

Width Of Road

Number Of Lanes

Road Surface

Eg. Tar, Gravel etc.

Visibility

Eg. Clear, Foggy

Street Lighting

Eg. On, Off

Were The Vehicle's Lights On

Which Vehicle Lights Were On

Weather Conditions

Eg. Cloudy, Raining

Police Details

Did the Police Visit The Scene *

Name of Police/Traffic Officer who recorded details of accident

Date Reported

Police Station

Police Station Reference Number

Was The Driver Tested for Drugs/Alcohol

Additional Information

Description Of Accident *

Upload Sketch of The Accident *

Click or drag files to this area to upload. You can upload up to 3 files.

Please provide a picture of a sketch of the accident using arrows to indicate direction of movement, a star to indicate position of impact and showing all road markings

Upload Photos of The Accident

Click or drag files to this area to upload. You can upload up to 20 files.

Please also provide a picture of the police report if available, this helps expedite claims.

Upload Clear Copy of Drivers license *

Click or drag a file to this area to upload.

Declaration

By Submitting This You Agree That The Information Supplied Is True And Correct In Every Aspect *

I Agree

Signature

Clear Signature

Motor vehicle accident claim form

Vehicle Details

Damage

Driver Details

Passengers In Insured Vehicle

Other Parties

Other Party Vehicles

Other Party Property

Witnesses

Accident Details

Police Details

Additional Information

Declaration

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