Hail Damage Claim Form - Execuline Motor Insurance Underwriters printable pdf download

Hail Damage Claim Form - Execuline Motor Insurance Underwriters

Fais No.: 5012 Reg No 2000/01333345/07

Hail Damage Claim Form

INSURED & BROKER DETAILS

Broker

Policy No:

Insured:

ID No. / Co. Reg No.

Occupation:

Cell No.:

Home No.:

Fax No.:

Email Address

Year:

Make:

Reg No.:

Model

Full Name:

ID No.:

Address:

Cell No.:

Work No.:

State fully the reasons for which the vehicle was being used:

Was the driver diving with your permission?

Was the driver in your employ?

DETAILS OF DAMAGE e.g. bonnet left side, left front fender, left headlight.

Area of Damage to vehicle (detailed)

Date(DD/MM/YYYY)

Time: (HHmm)

Occurred

Weather conditions

Visibility:

Sketch of Damage

(please show clearly where the damage is located on the vehicle)

I declare the foregoing particulars to be true in every respect.

Signature of Insured: ……………………………………………………………..

Date (dd/mm/yyyy): ………………………………………..

Signature of Driver (if not insured): …………………………………………….

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JUNE 2012

Hail Damage Claim Form - Execuline Motor Insurance Underwriters