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 Issue Date of Expiry  
Place of Issue      
Is it a Learner's Permit ? If Yes, Number  
Particulars of Theft / Fire Incident
Who discovered this loss      
Date Time  
No. of persons in insured vehicle No. 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
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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