CLAIM NOTIFICATION FORM

Reporting A Claim

We believe that a client's claim experience is an important aspect of insurance service and customer satisfaction. For this reason, claims are always handled with the utmost efficiency and consideration for the claimant. Claims can be reported verbally (i.e. in person or via the telephone) and followed in writing (i.e. letter, e-mail or a completed claim form) to our main office or any of our Agents nearest to you. Claims are normally processed and settled within TWO WEEKS provided that:
  1. A written police report is provided without delay (applicable to motor claims)
  2. A fire department report is provided without delay (applicable to property damage by fire)
  3. Two original estimates of repairs for damages is provided without delay (applicable to motor and property claims)
  4. Medical receipts and a doctor's report are provided without delay (i.e. claims of bodily injury to third parties resulting from a motor accident).

This form is intended to obtain preliminary information only. Please note that no liability is admitted by the issuance of this form. Please be sure to answer all the questions below and let us know how to contact you.

Type of Claim: Motor Fire
Other Specify
Name of Claimant:
Claimant's address:
Claimant's contact information
Email:
Telephone No.:
Fax No.:
Name of Policyholder:
Policy Number:
Policyholder's contact information:
Email:
Telephone No.:
Fax No.:
MOTOR
Date of Incident:
Time of Incident:
Where did it occur (i.e. address & location)?
Description of Insured's vehicle involved in incident:
Year: Model:
Make: Plate No.:
Description of Third Party's vehicle involved in incident (if applicable):
Year: Model:
Make: Plate No.:
Third Party Property Damage: Yes No
Third Party Bodily Injury: Yes No
Fire & Other
Other (Please Specify):
Date of Incident:
Time of Incident:
Briefly describe the incident:
Where did it occur (i.e. address & location)?
Briefly describe the damages:

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