Motor Vehicle Accident Claim Form (Page 2 of 4) in pdf

5. Particulars of Driver

Name in Full

Date of Birth

Address

Licence No.

Date of Expiry

Date First Licensed

Licence Issued by

For Vehicle Classes

Licence Status

Learner

Restricted

Full

Overseas

Never Licensed

Disqualified

Please state (giving full particulars)

1. If the vehicle was being driven with the owner’s knowledge and consent Yes

......................................................................................................................................................................................................

2. If the driver’s licence has been endorsed or suspended Yes

(when and why)

......................................................................................................................................................................................................

3. If the driver is the owner

employee

relation

and/or friend

.......................................................

4. If the driver owns his own vehicle Yes

(name of Insurance Company) .......................................................

5. If the driver has a policy of insurance cancelled or declined

or an excess or increased premium imposed

......................................................................................................................................................................................................

6. If the driver has been involved in previous accidents Yes

(name Insurance Company)

......................................................................................................................................................................................................

7. Amount of liquor consumed by the driver during the 24 hours preceding the accident, including when and where?

......................................................................................................................................................................................................

8. Has Police action been threatened? Yes

(charge and identity of person required) ...........................................

9. Was a breathalyser test required? Yes

What was the result? ..........................................................................

Was a blood test taken? Yes

What was the result? .........................................................................................

10.If the driver has had any traffic or criminal convictions? Yes

...................................................................

6. Witnesses

Please give names and addresses of all witnesses:

1. Passengers in your vehicle

Phone No.