Tricycle Creditstar Microinsurance

MOTORCYCLE/TRICYCLE CLAIM FORM

Instruction: Use ( ) or underline where appropriate.

NOTE: The Company does not admit liability by the issue of this form.
i. The information provided is to enable the Company’s Solicitors to advise on and to conduct any legal proceedings which may ensue
ii. Kindly provide picture evidence of the damaged property or bodily injury/death as a result of an accident.

PART A: POLICY DETAILS

POLICY NO:

INSURED VALUE:

Period of Insurance: From:

Period of Insurance: To:

Type of Cover?:

PART B: INSURED’S DETAILS

FULL NAME:

TELEPHONE:

Address

BUSINESS REG NO (if applicable):

PART C: RIDER’S DETAILS

FULL NAME:

TELEPHONE:

DOB:

RIDER’S LICENSE NO::

Address

PART D: MOTORCYCLE/TRICYCLE DETAILS

TYPE (motorcycle or Tricycle)

MAKE

REGISTRATION NUMBER

COLOUR

CHASSIS NUMBER

ENGINE NUMBER

PART D: LOSS DETAILS

(i) The purpose for which the claim is being filed:?:

Purpose of usage at the time of loss:

Location of Accident/loss:

Time of Accident: _ _:_ _ am/pm format HH/MM

Date of Accident: _ _/_ _/_ _ _ _ (format dd/mm/yyyy):

Name of the person riding at the time of loss

IF IT'S THE RIDER:

(i) Did he have the consent of the insured?:

(ii) Was he in the Insured’s employ?:

(iii) If yes, how long has he been employed?:

(iv) Was the motorcycle/tricycle locked?:

If yes, how long has he been employed?

Describe the circumstances under which the loss occurred.

Please provide details of the visible damage to third party/third party property (name and address included).

(v) Is there any hire purchase interest?:

If the accident resulting to death was reported at the police station, please state the police station:.

Date: _ _ / _ _ / _ _ _ _ (format dd/mm/yyyy).

Address:.

PART D: LOSS DETAILS

Please state full names and contact details of person (s) who can confirm the accident:(Name/Phone numbers/Email address):.

Independent witness:

If any person received treatment at the scene of the accident or was taken to the hospital, please provide the names and contact details of the injured persons, of the attending doctor, and the hospital :

DECLARATION

I/We hereby declare that the above information and facts are true to the best of my knowledge connected with the accident.

Signature of Driver: .

Date: _ _ / _ _ / _ _ _ _ (format dd/mm/yyyy).

Signature of Policyholder:

Date: _ _ / _ _ / _ _ _ _ (format dd/mm/yyyy).

IF THE MOTORCYCLE HAS BEEN DAMAGED, A DETAILED ESTIMATE SHOULD BE SUBMITTED AS SOON AS POSSIBLE BUT THE REPAIRS SHOULD NOT BE CARRIED OUT WITHOUT THE APPROVAL OF THE COMPANY UNLESS WITHIN THE LIMIT PERMITTED BY THE POLICY.

MOTORCYCLE/TRICYCLE CLAIM FORM

PART A: POLICY DETAILS

PART B: INSURED’S DETAILS

PART C: RIDER’S DETAILS

PART D: MOTORCYCLE/TRICYCLE DETAILS

PART D: LOSS DETAILS

IF IT'S THE RIDER:

PART D: LOSS DETAILS

DECLARATION

IF THE MOTORCYCLE HAS BEEN DAMAGED, A DETAILED ESTIMATE SHOULD BE SUBMITTED AS SOON AS POSSIBLE BUT THE REPAIRS SHOULD NOT BE CARRIED OUT WITHOUT THE APPROVAL OF THE COMPANY UNLESS WITHIN THE LIMIT PERMITTED BY THE POLICY.

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