TEST – MOTORONGELUK Form

INSURER
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Broker / Agent
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Name and occupation
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Identity number
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Address and (day) phone no.
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Model and Year
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Make
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Registration no
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Value
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Date of purchase and price paid
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Tare
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Gross Veh. Mass
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Km completed
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If vehicle subject to Hire Purchase, Credit or Leasing Agr. State name of Fin Com
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In whose name is vehicle registered?
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Damage to own vehicle
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Estimate for repairs or attach quotation
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Attach Quote
Upload your documents...
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Repairer’s name, address and telephone number
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Where can you damaged vehicle be inspected?
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Full Names
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Address
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Occupation
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Identity Number
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Driving Licence

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No.
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Select a date
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Place
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Full / Learner
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State fully the purpose for which the vehicle was being used
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Was he/she driving with your permission
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Was he/she in your employ?
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Is he/she owner of another vehicle? If yes, give name of insurer and policy number
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Details of any convictions for motoring offences
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Has licence ever been endorsed
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Has he/she any physical defects
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Details of previous accidents
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Passengers in insured vehicle
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Other party

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Passengers in insured vehicle
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Property other than vehicles

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Name and address of owner
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Details of damage
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Property other than vehicles

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Personal injuries
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Details of witnesses
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Date, time and place of accident
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Speed

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Before accident kph
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Weather conditions
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Road surface
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Which vehicle lights were on
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Moment of inpackt kph
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Visibility
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Width of road
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Street lighting
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Was any warning given by you e.g. hooting, indicator, etc
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Name of Police/Traffic officer who recorded details of accident
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Police Station
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Reference No.
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Was driver tested for alcohol or drugs?
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Description of accident
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Upload Pictures
Upload Pictures
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I have inspected the driver’s licence and it is free of endorsements / endorsed as shown.

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Signature:
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Please attach copies of driver’s licence and page 1 of driver’s identity document.
Please attach copies of driver’s licence and page 1 of driver’s identity document.
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We hereby declare the a foregoing particulars to be true in every respect

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Signature of Driver
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Signature of Insured
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Select a date
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Submit