NAF 05 - 48 c
MOTOR CLAIM SICOM General Insurance Ltd
Sir Celicourt Antelme Street, Port Louis
NOTIFICATION OF ACCIDENT FORM t: (230) 203 8407 / (230) 203 8400 f: (230) 208 9373
e: [Link]@[Link] | w: [Link]
CLAIM No : ..........................
All questions must be answered fully. This claim form when completed must be returned to SICOM General Insurance Ltd (hereinafter referred to as
the Company) without delay. THE COMPANY DOES NOT ADMIT LIABILITY BY THE ISSUE OF THIS FORM.
Insured Details Name: .......................................................................... Occupation: ................................................
Address: ........................................................................ Employer: .................................................
Tel No: .............................. Email: ............................................................ VAT Reg No: ......................
Insurance (a) Policy No: .................................................. (b) Type of cover: .......................................................
(c) Excess: ..................................................... (d) Period: .................................................................
Year of Make Regd No H.P or C.C Year of Purchase Make / Model Sum Insured
Vehicle
Has any party a financial interest in the vehicle?
Yes No
Lien
If yes, give details ..........................................................................................................................
For what purpose was the vehicle being used at time of accident? ..................................................................
Purpose of use
Was the vehicle in use with the Insured’s permission or consent? ....................................................................
Name: ................................................................................. Date of birth: ......................................
Driver Details
Address: ............................................................................... Occupation: .......................................
Tel No: Home: .................................. Office: ................................... Mobile: ....................................
Driving Licence No: ........................... Date of FIRST issue: ........................ Date of expiry: ........................
Category of licence: ....................................................................... Endorsed/Suspended: Yes No
Note: THE DRIVER’S ORIGINAL LICENCE MUST BE SENT TO THE COMPANY FOR INSPECTION.
• Do you have any physical incapacity? Yes No
If yes, give details: ........................................................................................................................
• Have you been involved in any previous accident? Yes No
If yes, give number and details .........................................................................................................
• Have you been prosecuted for any motoring offence? Yes No
If yes, give details .........................................................................................................................
• Have you ever been refused a motor vehicle insurance or continuance thereof by any insurer? Yes No
If yes, give full details ....................................................................................................................
• Do you own a motor vehicle? Yes No
If yes, give registration no. and insurer ...............................................................................................
• Are you employed by the Insured ? Yes No
If yes, in what capacity and for how long? ............................................................................................
If no, state relationship to Insured .....................................................................................................
Please show names and approximate width of roads and indicate tracks of vehicle.
Rough Plan of
accident
Page 1 of 2
Particulars of Date: ........................... Time: ................. am/pm Place: ....................................................................
accident Road and weather conditions ................................................................................................................
• At what speed were you travelling at time of accident? ..............................................................................
• Were traffic lights in operation at scene of accident? Yes No
If yes, were they in your favour? Yes No
• If the accident happened at night were there any road lights at scene of accident? Yes No
Full description of accident and events leading up to accident:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
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NAMES AND ADDRESSES OF ALL WITNESSES
PASSENGERS INDEPENDENT
Witnesses
of accident
• Have you reported the accident to the Police Station? Yes No Date and time reported: ..............................
If yes, which Police Station? ...............................................................................................................
If No, reason for not reporting: ...........................................................................................................
• Do you accept responsibility for the accident? Yes No If No, who is responsible:.............................
• Has any alcohol test been carried out? Yes No If Yes, specify result: ..................................
• Is the vehicle damaged? Yes No If yes, extent of damage: .............................................................
....................................................................................................................................................
Damage to
Repairs to be carried out at Garage: ....................................... Address: ....................................................
Insured’s
vehicle NO REPAIRS TO BE CARRIED OUT TO THE VEHICLE UNLESS THE ESTIMATE OF COST OF REPAIRS IS APPROVED BY
SICOM GENERAL INSURANCE LTD
Name / Insurer Address Make & Regd No Damages
............................... ................................ ................................ ................................
Particulars of
other parties ............................... ................................ ................................ ................................
involved in the
accident ............................... ................................ ................................ ................................
Name and Address of injured Driver or passenger in own or Details of injuries State Hospital or name and
other vehicle? address of Doctor consulted
Injuries Relationship to insured or driver
............................... ................................ ................................ ................................
............................... ................................ ................................ ................................
............................... ................................ ................................ ................................
Customer We hereby declare the foregoing particulars to be true and correct in every respect and we undertake to render SICOM
Declaration GENERAL INSURANCE LTD all possible assistance in dealing with this matter. Concealment and Non-Disclosure may render this
claim null and void.
The Policyholder understands and agrees that personal data shall be exchanged amongst relevant insurers through a
common exchange portal, solely and exclusively for the purpose of claims handling and recovery processes. The Policyholder
understands and agrees that the exchange portal’s server shall be hosted by the Insurers’ Association of Mauritius in strict
accordance with applicable Data Protection laws.
Date: ......../......../................ Signature of Driver: ........................................
Date: ......../......../................ Signature of Insured: ......................................
For Office use only
Received by : ..................... Checked by : ..................... Remarks :
Date : ......./...... /............. Date : ......./...... /.............
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