Motor Insurance Claims Form – Union Commercial Claims & Complaints

*Policy Number

*Policy Type

*Name

*Surname

*Email

*Phone

Address

INSURED VEHICLE DETAILS

*Make and Model

*Year of Manufacture

*Vehicle Registration No.

*Engine No.

*Chasis Number

*Purpose of Use

Private

Commercial

*Does Driver Own The Vehicle?

Yes

No

Driver's Name

Driver's Contact Address

Date

*Driver License Number

Date of Issue

Date of Expiry

*Date of Accident

*Time of Accident

Road Condition

Weather Condition

*Description of Accident

WITNESSES

*Witness 1 (Name)

*Witness 1 (Address)

Witness 2 (Name)

Witness 2 (Address)

Witness 3 (Name)

Witness 3 (Address)

*Third Party Full Name

*Third Party Address

*Third Party - Vehicle Make

*Third Party - Year of Make

*Third Party - Vehicle Reg No.

*Is Owner Insured

Yes

No

Affirmation

I affirm that all information provided are accurate and my insurance company reserves the right to refute my claim if found wanting.