Accident/Loss Report

Dear Policyholder,

This Accident/Loss Report form should be filled out if your vehicle, which is insured with the Hand-in-Hand Group, has been involved in an accident.

Please note that your insurance contract requires you to notify us in writing, or as we are allowing, via the below form, and to give all information and assistance we may require.

Please complete and submit this Accident/Loss Report Form as soon as possible.

Remember, any letter, claim, writ, summons and/or process must be forwarded to this company immediately upon receipt. You must also immediately notify us in writing should you have knowledge of any impending prosecution in respect of this accident.

Failure to complete and submit this form may result in the loss of any benefits under the insurance policy.

Accident/Loss Report Form

    Note: Enter “N/A” where a field does not apply.

    Name
    Policy No.

    Address
    Private Tel. No.

    Business Tel. No.

    Occupation

    Is there any other insurance which might apply?
    If so, name of other Insurers

    Make
    Cubic Capacity
    Year of Make
    Registration No.

    Is the vehicle your property?
    If not, please state Owner/H.P. Co.

    Was vehicle's use connected with occupation of Insured or driver?
    If so, please give precise details
    If not, for what purpose was it being used?

    If goods vehicle, give details of operator's Licence currently held
    Plated weight of vehicle

    Nature of load
    Weight of load
    Were the goods carried your property?

    If passenger hire, number of passengers
    How was the vehicle so hired?

    Name

    Date of Birth

    Occupation
    Address

    Does driver hold current driving licence for vehicle of above type?
    If so, is it Full, Provisional, Permitted or International?

    Name of Issuing Authority
    Licence No.
    Period valid

    If full licence held, has statutory driving test been passed for the above type of vehicle?

    Date of Issue
    Licence I.D. No.
    Class of vehicle licenced to drive

    Has driver ever been prosecuted, disqualified or are proceedings pending for any alleged motoring offence?

    If so, state particulars of any convictions recorded

    Is driver in your direct employ?
    If so, for how long?

    Has he a motor Insurance policy in his own name?
    If so, Insurer and Policy No.

    Incident Date
    Time
    If after turning on vehicle’s lights, how was your vehicle lit?

    Place/Location
    Weather conditions

    Did your driver give warning?
    If so, how?

    Did other driver give warning?
    If so, how?

    Speed of your vehicle (a) immediately before
    (b) at moment of Impact

    Please describe exactly how accident occurred

    Please upload up to 4 photos…




    In your opinion who was to blame?


    OWN DAMAGE

    Own Damage — Particulars of damage to Policyholder's vehicle
    Repairer's name and address

    Estimated cost of repairs?
    Repairs been instructed?

    Where can vehicle be inspected?


    WITNESSES

    Witnesses — Independent (names & addresses)
    Witnesses — Own Passengers (names & addresses)

    Did a Police Officer take particulars of the accident?
    If so, give Number and Station

    Did the driver make a Statement to the police?


    THIRD PARTY

    Third Party — Name and address of Owner and/or Driver of other vehicle
    Name and address of his Insurers (if Known)

    Registration No.
    Damage

    Name and address of injured person(s)
    Nature of injuries

    To which Hospital, if any, was injured person taken?

    Name and address of Owner of damaged property
    Damage (state whether verified verbally or in writing)