CORNERSTONE INSURANCE PLC

RC:163170
21, Water Corporation Drive, Off Ligali Ayorinde,
P.O BOX 75370, Victoria Island, Lagos.
Tel: 234-1-2806500 Fax: 28006526-7
E-mail: claimscare@cornerstone.com.ng Website: www.cornerstone.com.ng
enquiries@cornerstone.com.ng
MOTOR CLAIM FORM
The issue of this form is not to be taken as an admission of liability

POLICY NUMBER: AGENT:

INSURED’S DETAILS
Name: Mobile Number:

Address: Email:

At the time of the accident, who drove the vehicle? Insured Insured’s Driver Others

DRIVER’S DETAILS
Driver’s Name: Phone Number:

Address:

Driver’s License Number: Date of Expiry:

VEHICLE DETAILS

Reg. No Make Year of Make Mileage Use (Commercial

or private)

Is the vehicle at the repairer’s? Yes No Name and address of repairer where the vehicle can be
examined: Phone Number:

DETAILS OF LOSS
Date of accident: Time of accident (am/pm)

Place of Accident: Road and weather conditions:

Was the accident reported at the police station? Yes No
Type of loss: Own Damage Third party Own Damage & Third party

Full description of Accident:

Who do you consider was at fault? Myself Third Party Driver No one Others

THIRD PARTY DETAILS (Where the insured is negligent or where the third party is negligent)

Name:

Mobile Number: Insurer:

I/We …………………………………………….………. declare that the information provided above are true and complete. I/We understand that should any
information provided above be found to be false or incomplete, I/We shall be liable to face consequences, which may include
invalidation/repudiation of the claim and/or legal actions. I/We also understand that the information given on this form may be submitted to
Solicitors for use in connection with any litigation arising from this accident.

Signature of Insured Date: