SUBMIT YOUR CLAIMS HERE

1Your details

2Claim Details

3Summary

PARTICULARS OF CLAIM

Please fill-in Insured details

Policy/Cover
Note No.:
Receipt No.:
Date Paid:
Type of Cover:
Period of insurance

From:
To:
First Name:
Last Name:
Address:
Occupation:
Telephone:
E-mail Address:
Attach copy of Covernote.

Add file

Maximum file size: 2MB

Please fill-in your details

VEHICLE' DETAILS

Make:
Model:
Year:
Registration No:
Engine No:
Chassis No:
Colour:
Is the vehicle subject to any loan of hire purchase arrangement?

Yes No
Attach copy of vehicle registration certificate.

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Maximum file size: 2MB

DRIVER'S DETAILS

First Name:
Last Name:
Date of Birth:
License No.:
Class:
Date Obtained:
Attach copy of driver license.

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Maximum file size: 2MB

LOSS/DAMAGE/THEFT DETAILS

Date:
Time:
Speed:
Place:
Purpose for which the vehicle was being used at time of accident:
Brief description of damages:
Location of the damaged vehicle:
Attach copy of quotation.

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Maximum file size: 2MB

POLICE INFORMATION

Was the accident reported to the police?

Yes No
Date and Time reported:
Name of
Police Station:
OB No.:
Did Police visit the scene of accident?

Yes No
Name of Police Officer and I.D. No.:
Who was charged for causing the accident?

Myself/My Driver The Third Party
Attach copy of police report.

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Maximum file size: 2MB

NB: If Third Party was at fault, you are advised to claim from his/her insurance company to avoid losing your No Claims Discount (NCD) at renewal.

Back

STATEMENT

Statement of how the accident happened (Driver to complete this part)

SKETCH

Sketch of scene of accident with names of roads and position of vehicles: (Driver to sketch)

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Maximum file size: 2MB

IF THE ACCIDENT INVOLVES A THIRD PARTY, PLEASE INDICATE

Vehicle Owner:
Telephone:
Name of Driver:
Email:
Physical AdDress:
Vehicle Registration No.:
Make:
Model:
Engine No.:
Chassis No.:
Name of Third Party Insurer:

THIRD PARTY PROPERTY DAMAGE

Brief description of damage:

DRIVER/PASSENGER/THIRD PARTY INJURIES

Name
Address
Phone No
Nature of Injury

Name
Address
Phone No
Nature of Injury

Name
Address
Phone No
Nature of Injury

Name
Address
Phone No
Nature of Injury

Name
Address
Phone No
Nature of Injury

Name
Address
Phone No
Nature of Injury

Name of hospital where the injured persons were attended to

Back

Policy/Cover Note No.:
Receipt No.:
Date Paid:
Type of Cover:
Period of insurance

From: To:
First Name:
Last Name:
Address:
Occupation:
Telephone:
E-mail Address:

VEHICLE'S DETAILS

Make:
Model:
Year:
Registration No:
Engine No:
Chassis No:
Colour:
Is the vehicle subject to any loan of hire purchase arrangement.

DRIVER'S DETAILS

First Name:
Last Name:
Date of Birth:
License No.:
Class:
Date Obtained:

LOSS/DAMAGE/THEFT DETAILS

Date:
Time:
Speed:
Place:
Purpose for which the vehicle was being used at time of accident:
Brief description of damages:
Location of the damaged vehicle:

POLICE INFORMATION

Was the accident reported to the police?
Date and Time reported:
Name of Police Station:
OB No.:
Did Police visit the scene of accident?
Name of Police Officer and I.D. No.:
Who was charged for causing the accident?

STATEMENT

Statement of how the accident happened

IF THE ACCIDENT INVOLVES A THIRD PARTY, PLEASE INDICATE

Vehicle Owner:
Telephone:
Name of Driver:
Email:
Physical Adress:
Vehicle Registration No.:
Make:
Model:
Engine No.:
Chassis No.:
Name of Third Party Insurer:

THIRD PARTY PROPERTY DAMAGE

Brief description of damage:

DRIVER/PASSENGER/THIRD PARTY INJURIES

Name of hospital where the injured persons were attended to

Back

Submit

Swan

SUBMIT YOUR CLAIMS HERE

PARTICULARS OF CLAIM

Please fill-in Insured details

Please fill-in your details

INSURED DETAILS

VEHICLE'S DETAILS

DRIVER'S DETAILS

LOSS/DAMAGE/THEFT DETAILS

POLICE INFORMATION

STATEMENT

IF THE ACCIDENT INVOLVES A THIRD PARTY, PLEASE INDICATE

THIRD PARTY PROPERTY DAMAGE

DRIVER/PASSENGER/THIRD PARTY INJURIES