Motor Accident

Claim Form Delete sections not applicable R

Zurich Insurance Company Botswana Limited

Registration No. CO/2043 VAT No. C00754501112
Head Office Sales Office
Zurich House, Fairgrounds Office Park Ground Floor, NDB Building
PO Box 1221, Gaborone, PO Box 670, Francistown,
Botswana Botswana
Telephone +267 3188888 Telephone +267 2412392
Facsimile +267 3188911 Facsimile +267 2413745

Policy No. Claim No.

Name and occupation

Insured

Address and Day Tel No.

Identity No./VAT No.

If vehicle subject to Hire Make Registration Model and Year Kilometers completed
Purchase, Credit or Leasing
Agreement
Vehicle

State name, address and account

number of finance company
Chassis/VIN No.
In whose name is the
vehicle registered?
Indicate old
Damage to own vehicle
damage on vehicle
Damage

Where is the vehicle at present?

Full name

Residential address

Occupation

Identity No.

an
Month and Date of issue
Drivers licence

ch
year of expiry and code issued

a of
State fully the purpose for
which vehicle was being used
a t t y
Was he/she driving with

a s e c o p
Driver

Ple
your permission?
Was he/she in your employ?
l e a r
d c ce
e n
Has he/she any motor
insurance on own car? If yes,

l a r g l i c e
n s
state Policy No. and Company
Details of any convictions for
e
i v e r
dr
motoring offences
Has licence ever been endorsed?

Has he/she any physical defects?

Details of previous accidents

Name Residential address Injury

Passengers (Insured Vehicle)

Passengers in insured vehicle

For what purposes were they

carried?
Are they employees?

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 Relationship to accident Name of hospital if
Name of Injured Details of injuries
e.g. driver, passenger etc. applicable

Personal injuries
(other than in insured
vehicles)

Registration Make Name of owner & driver Passport No.

(a)

(b)
Other Party

(c)
Other vehicles
Details of damage Old damage Address of owner & driver Colour of vehicle

(a)

(b)

(c)

Name and address of owner Details of damage

Property other than vehicles

Name, address and

Independent

telephone No.
Witnesses

Name, address and

telephone No.

Date, time and place

Speed Before accident kph Moment of impact kph

(a) Weather conditions
(b) Visibility (a) (b)
(a) Road surface
(a) (b)
(b) Width of road
(a) Which vehicle lights were on?
(a) (b)
(b) Street lighting
Was any warning given by you,
e.g. hooting, indicators, etc?
Name of Police/Traffic officer who recorded details of accident Police station, case number and date reported

Police details
Was driver tested for
Accident

alcohol or drugs?

DESCRIPTION
OF
ACCIDENT

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 SKETCH
OF
ACCIDENT
(if necessary use
separate page)

Please show clearly the

point of impact and
indicate the direction of
travel by arrows.
Give details of any road
safety signs or warning
signs in the vicinity
of scene of accident.

Insurers share information with each other regarding domestic policies and claims with a view to prevent fraudulent claims and
obtain material information regarding the assessment of risks proposed for insurance. Please refer to the Consent Clause on
the policy schedule for more details in this regard.

You may select, for added security, payment of any amount due to you directly into a bank account. Please specify the name of the bank, branch, name of
Payment method

account and account number.

Name of Bank Branch

Name of Account Account No.

I have inspected the drivers licence and it is free of endorsements/endorsed as shown.

Inspected
Licence

Signature of Insured Capacity Date

We hereby declare the aforegoing particulars to be true in every respect.

Declaration

Signature of Driver Capacity Date

Signature of Insured Capacity Date

N.B. It is important that you notify the insurers immediately you become aware of any impending
prosecution, inquest or demand

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