Initiate Claims

Car Theft/Accident Claims Form

Client Details








Vehicle Registration





Driver Details

 
Is Driving Licence in force ?If Yes, which category? 
Driver's License No.Has it been endorsed ? 
Date of IssueDate of Expiry 
Place of Issue   
Is it a Learner's Permit ?If Yes, Number 
Period   
     

Particulars of Theft / Fire Incident

Who discovered this loss   
DateTime 
No. of persons in insured vehicleNo. of persons in other vehicle 
Address of Police Report Station  
Full Statement of Theft/Fire Incident  
     

Damage to Insured Vehicle

Full details of damaged Parts  
Present Vehicle Location   
Rough Estimate of Repairs   
Repairer's Name  
Repairer's Full Address  
Inventory of damaged parts  
     

Third Parties involved in the Accident

Fullname  
Address   
Type of property/Injury   
If Vehicle, Make  
Registration No  
Year of Make  
Present Location of Vehicle   
Is Owner insured ?   
If Yes, Policy No   
Name of Insurer   
Address of Insurer   

Upload Picture Evidences

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Note: You can select multiple pictures to upload (MAX OF 2). Select both images at the same time by holding down the SHIFT KEY or you can add them one after the other.
    
    
     
 DECLARATION - I/We declare the foregoing particulars to be true and I/We authorize EQUITY ASSURANCE PLC (EAI) and/or their Legal representatives to deal with all matters arising from this accident at their discretion and if they deem it expedient to admit liability and/or negligence on the part of myself/our servants or Agents
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