Submit Motor Accident Claim

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.

Title

Surname ^*

Forename(s) ^*

All forenames separated by space

Postal address

Residential/Business Address ^*

Policy number ^*

Home

Business

Mobile phone ^*

Fax

Contact person

Motor Vehicle Details

Make and model ^*

Year

Registration Number ^*

Mileage

Is the vehicle subject to a HP agreement?

YES NO

Name of Company

Name of driver ^*

Date of birth

Address of driver ^*

License # ^*

Date of issue

License class

Vehicle use ^*

Time and Place of Accident

Date of accident ^*

Time

Weather conditions ^*

Accident Place ^*

Roadway and conditions ^*

Vehicle Direction ^*

Side of the road? ^*

Your speed? ^*

Brake Condition? ^*

Police attend?

YES NO

If the police did not attend did you report the accident?

YES NO

Which station?

TAB number?

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

Name of Owner

Address

Type of property

Type of property and Extent of damage

Registration number

Is insured?

YES NO

Insurance Company

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

Parts damaged and Extent

Who caused the damage?

Address of person who caused the damage

Vehicle is insured?

YES NO

Name of insurer

Where can vehicles be seen?

DRIVER’S ACCOUNT OF ACCIDENT OR LOSS

Accident Details

Attach Sketch Plan

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.

Motor Vehicle Details

Time and Place of Accident

Details of persons in your vehicle at the time of the accident:

Persons injured:

Damage to property of others

Names and addresses of witnesses (IMPORTANT)

DAMAGE TO YOUR VEHICLE

DRIVER’S ACCOUNT OF ACCIDENT OR LOSS

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.