Register | Accident Management System

Details of Insured Company

Insured's Reference *

Capulus Reference *

Policy Number *

Insured's Name *

Address *

Postal Code *

Tel no. *

Subsidiary or Depot )or subsidiary / location code) *

Details of Insured Driver

Name *

Occupation *

Employer's Name *

Address *

Postal Code *

Tel no. *

Contact Telephone Number of different from above

Age *

Licence type *

Licence Number *

How Long Held (Years) *

Any convictions? (if Yes Give details seperately) *

Details of Insured Vehicle

Registration No. *

Make *

Model *

Manufacture Year *

Value *

Name and address of owner if different from above

Postal Code

Tel no.

Location of Vehicle *

Postal Code *

Tel no. *

Are you claiming repair under the policy? *

Yes No

Estimated cost of Repair

Vehicle Is

Details to Any Damage to the Vehicle *

Brief description of damage to vehicle *

Details of Accident

Date *

Time *

Weather Condition *

Condition of Road Surface *

Location of Accident (Nearest Town) *

What lights were showing on your vehicle? *

What lights were showing on other vehicle? *

If police were involved give officer's number and station *

Please give details of any warning / prosecutions pending against any party *

Speed of Vehicle - Before Impact *

Speed of Vehicle - After impact *

Did any body sound their horn? *

Yes No

Details of other Vehicles Involved / Property Damaged

1)Name and address of driver / property involved *

Postal Code *

Tel no. *

Make *

Model *

Registration Number *

Vehicle Colour *

Insurer *

Policy Number *

Apparent Damage *

Owner of Vehicle of Different from above? *

# of people in vehicle( including driver) *

2) Name and address of driver / property involved

Postal Code

Tel no.

Make

Model

Registration Number

Vehicle Colour

Insurer

Policy Number

Apparent Damage

Owner of Vehicle of Different from above?

# of people in vehicle( including driver)

Details of Persons Injuried (including fatalitites)

1) Name

Postal Code

Tel no.

Injuries

Travelling in which vehicle?

Any treatment administered?

Hospital to which taken?

Detained

2) Name

Postal Code

Tel no.

Injuries

Travelling in which vehicle?

Any treatment administered?

Hospital to which taken?

Detained

Witnesses (including passengers in your vehicle)

1) Name

Address

In a Vehicle

Yes No

# of Passengers in Vehicle

Ask if any witness's

Postcode

Tel No.

2) Name

Address

In a Vehicle

Yes No

# of Passengers in Vehicle

Ask if any witness's

Postcode

Tel No.

Plan of accident (showing road markings, signs and directions of travel with measurements if known)

Plan of accident *

Circumstances of accident (state fully what happened)

Circumstances *

Upload Pictures*

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Upload Video*

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Signing Declaration

Drivers name *

Geo Stamp Location *

Digital Signature *

I declare these details to be true