• Main Details
  • Accident Details
  • Third Party Details

Claim Form

Complete and Accurate information must be given in this Claim. Zimnat reserves the right to verify the authenticity of all submitted documents and to prosecute any fraudulent actions
All Fields marked with * are mandatory.

All forenames separated by space


Motor Vehicle Details

Time and Place of Accident
Details of persons in your vehicle at the time of the accident:
Name Address Age Relationship
Persons injured:
Name Address Age Relationship
Damage to property of others
Names and addresses of witnesses (IMPORTANT)
Names and addresses of witnesses, bystanders or person in the immediate vicinity who may have seen the accident or heard statements made by any person involved.
Name Address
DAMAGE TO YOUR VEHICLE
DRIVER’S ACCOUNT OF ACCIDENT OR LOSS