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CLAIMS – MOTOR

Broker and Insurer Details




Vehicle




Damage






Driver



















Passengers Insured Vehicle













Third Party Details (Other Party)










Property Damage (Other than Insured Vehicles)

Witness


Accident Details

Before Accident









Moment of Impact









Detailed Description of the Accident

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PLEASE NOTE: By clicking "Submit Claim Request" you hereby solemnly declare that the information above and on the face hereof is a true and faithful account of the event/damages sustained and that to your knowledge nothing has been concealed which may be relevant to consideration of this claim.