Motor Claim

The issue of this form is NOT an admission of liability on the part of the Company. Please answer all questions fully and return form without delay to ALLIANZ NIGERIA INSURANCE LTD

I/WE OF

hereby declare that all information provided by me/us pertaining to the claim below has been wholly and honestly supplied to ALLIANZ NIGERIA INSURANCE LTD are complete, true, authentic and verifiable.

1 Basic infomation Name: * Vehicle Reg No: E-Mail: * Telephone Number * BVN Is the driver same as insured? Did you get third party details?

2 Driver’s Details (Complete if not same as policy holder) Driver’s Full Name: * Address: Phone Number: * Driver’s Relationship to Insured: Does he/she hold a license?: If yes, provide a copy

Was there any admission of responsibility for the accident If yes, give details

3 Details of Accident/Theft

Third PartyProperty Damage

Accidental Damage toOwn Vehicle

Theft/Vandalization

Fire Damage

Third Party Injury/Death

Date of Loss Vehicle Reg. No * Location of Theft/Accident Time of Theft/Accident Narration of Accident

4 Third Party Details (Please complete following if other vehicles were involved or other property damaged) Name ofthe third party vehicle owner/driver Vehicle make/model Vehicle RegNo Describe the damage to the third party vehicle/property Phone No Email Insurance details (Provide evidence/certificate)

Home/ office address

5 Witnesses, including all your passengers (Use additional sheets where necessary)

Witness.No : Name Mobile No Address Where was the witness when the accident occurred

I/We authorize the Company and/or their Legal representatives to deal with all matters arising from this claim at their discretion and if they deem it expedient, to admit liability and/or negligence on the part ofmyself / our servant or agents.

Signature

Date & Time

6 Kindly provide the following document to fast track claim settlement Repair Estimate Invoice attachment

Photograph of Damage

License
Police Report

ACCOUNT NAME
BANK NAME
ACCOUNT NUMBER