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