Motor Claim Form

Particulars of Driver
Name of Driver
Date of Birth
DD slash MM slash YYYY
Postal Address
Occupation Status
Telephone
The driver is
Type of Driving License
Country of Issue
Expiry Date
DD slash MM slash YYYY
Date Passed Driving Test
DD slash MM slash YYYY
Permitted Groups
- Ηas the driver ever been convicted of driving or motoring offence or is any prosecution pending?
If yes,please give details
- Has the driver ever been involved in an accident before?
In case of employees, how long is in your employment?
- Is there any other insurance covering you or the driver in relation to the accident?
- If the driver is an employee/relative/friend of the insured does he own a car or motorcycle?
If yes, inform of the insurance company:
DAMAGES OF INSURED VEHICLE
Details of damages
Workshop name
Telephone
When is the vehicle going to be repaired?
MM slash DD slash YYYY

DETAILS OF THE ACCIDENT
Date
DD slash MM slash YYYY
Time

: Hours

Minutes

AM/PM
Speed
Place
- Did the police attend?
Name and No. of the Policeman
Police station
Passengers
Witness | Νame & Address of any independent witness
Description of the accident
PARTICULARS OF THIRD PARTIES (VEHICLES, PROPERTY)
Owner's name
Owner's address
Owner's telephone
Driver's name
Driver's address
Driver's Telephone
Driver's registration No.
Vehicle Make
Insurance Company
Cover
Policy Number
Details of Damages
Workshop Name
Telephone
Passengers
PARTICULARS OF INJURED PERSONS
Name
Address
Nature of injuries
Age
Number
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*
- I have read the Data Protection Company Policy posted on this website I herewith provide Royal Insurance Company Ltd (and any successors and assignees thereof), my express and unconditional consent regarding the processing and creation of data records in electronic and physical form, of all my relevant personal data, that may include sensitive data which I have declared and submitted

Insured Vehicle