Wewesioas + EFU ie 1/4 Sd Rod NOTICE OF Ropero m pee oe ACCIDENT FORM GENERAL festoncsctuvene (MOTOR VEHICLE) MA, Jinnah Road, Korochi-74000 INSURANCE: 221247120 ate iD. crore i Pi Enid 1922 THIS FORM MUST BE RETURNED TO THE COMPANY IMMEDIATELY WITH ALL QUESTIONS FULLY ANSWERED WHETHER A CLAIM IS LIKELY TO ARISE OR NOT. The Company does not admit liability by the issue of this form. Please read this form through before filling in details. CLAIM NO.. POLIGY NO.________ EXPIRY DATE Tol. No Mobile No. Motor Cycle: (1) Was Side car Attaches? (@) Wasa Palion Riser career? many atthe tenet PARTICULARS | Was Vehicle in proper onfor and eoneliton OF VEHICLES | “He tre”. ‘CONCERNED IN ACCIDENT "Goods Carrying” Vehicle:- In policy-holdor the owner of the Venlo? (1) State nature and approximate Weight of load carried? (2) Was a Taller ainched. asthe VebiceBang uel wth the Sonate unwed tnd cones?DRIVER STATE HOW ACCIDENT LOSS: OR BREAKDOWN OCCURRED WITNESSES: {tis most important that Names and ‘Addresses of all independent Witnesses of an Accident should be} ‘obtained, whether the Driver eonsic ‘inset to blame oF fot Name of Driver at ime of Accident Age ‘Address of Driver = wone { creviearnsoer Shia seemed oor toa fe lacicies toe precio ieee cal ec onion sat br bes sinh Pirseralislamah pede ee recor Estima’ Spoed of your Vehicle ‘Mies par Hour Give full description of cident. Loss oF Breakdown, ‘Give names and addresses of al wnessen of Accident or { incar Independent ‘Winesses Wines namas rot taken, give reason (Dd a Poicoman wines Accident or tke particulars? Potcemarts No. ‘eas any statement, a to faut, mace by witnaeses or Drivers atthe tine? ‘wat the matter reported to the Posce? it 0, give name and across of Poko Staion and state what action, i any, has 0s ing akan not reported 16 the Polen” the reasons lor tho samo.PARTICULARS: OF DAMAGE OF INJURY TO THIRD PARTY (PROPERTY OR PERSONS) PARTICULARS (OF DAMAGE TO INSURED VEHICLE THEFT Name Address Ful extent of Personal Injuries or Oamage to Property ‘any injured person has been removed to hospital oF medically attended, give name and address of the Hospital or Doctor Has notice of any Ciaim been to you? nau: Policy No. ‘Adi ro asaty ary ercumatarces EA Geapaich Wo the Company torte anc nareered any wire communication which may hawe been mee Full Particulars of Damage "Whore the Vehicles can be inspected: ‘Estimated cost of Ropar inthe event of damage to tyres as a result of tha Accident sat: When putchased_______ Approximate Milaage done thas it been Retreades?___ Wh ‘An oxtnate of cost of pair should immectately bo obtnined and forwarded to the Company ALSO TO BE FILLED IN, IN CASE OF THEFT. W Loss occured while vohicle was standing in street, was it unattended? 1150, how tong? 11 Car was in garage, was forcible entry made, if 0, in what manner? ‘Have the Police bean advised? if 0, when and with what result? no why not? Was any damage inflicted to the Car? Please state any turthor particular, f any FLA and Fina Poles investigation Report 10 be obtained and forwarded io the Company,4s there any other Policy indemniting your or the Driver in reepect or this accident? s0 tre name'of insurers, the Policy Number and the sum insured Declaration : We hereby declare the foregoing particulars ta be true in every respect and claim under the Policy the amount of my/our loss. Insured's Signature, Datedapa iso0010KF MOTOR CLAIMS (ACCIDENT DEPARTMENT) GENERAL SATISFACTION NOTE + bess No. Dated hereby acknowledge having received from Messrs. the Repairers, my” Registered No. duly repaired and in complete running order to rm satisfaction and in consideration of setting the repairs Bill amounting to Rs. _____of the aforesaid, | hereby give this discharge to ££ eammu msurance i. Under their policy No. in full and finol settlement of claims, present or future arising directly or indireclly, out of the accident which occurred to my aforesaid vehicle on the 200 Signature of the Owner (Insure) Address