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CAR ACCIDENT

This declaration should be completed and sent to the company within 48 hours from the date of accident. Sending this declaration does not implicate the company in any responsability.
IMPORTANT:

The insured and any other person should not admit any responsability without refering to the company.

   
 
Insured Name
required
Policy No
required
 
Address
Email
required
 
   
 
Car Model
required
Registration No
required
   
Driver Name
required
Driver Age
 
 
Driver Address
Driving Permit NO
required
 
   
 
Issuance Date
required
RadDatePicker
Open the calendar popup.Open the time view popup.
Accident Place
 
City/Street  
 
Did any Official Authority Investigate the Accident?  
Accident Date
required
RadDatePicker
Open the calendar popup.Open the time view popup.
 
 
 
Describe Accident
 
Witnesses Name Witnesses Address
1. 1.
2. 2.
3. 3.
 
 
Persons in the car during accident
 
Name Address
 
1. 1.
 
2. 2.
 
3. 3.
 
Police Report? Called Expert?
 
 
Expert Name Damages
 
 
In case of bodily injured
 
Insured Name Insured Address
 
Telephone Hospital
 
Information related to third party 1
 
Car Owner Name Car Owner Address
 
Driver Name Driver Address
 
Car Model Registration No
 
Information related to third party 2
 
Car Owner Name Car Owner Address
 
Driver Name Driver Address
 
Car Model Registration No
 
Information related to third party 3
 
Car Owner Name Car Owner Address
 
Driver Name Driver Address
 
Car Model Registration No
 
 
Damages of third party
I declare that I have answered all above questions as to the best of my knowledge and I pledge to provide Capital Insurance & Reinsurance Co. sal all possible assistance in relation to this accident. I also declare that I do not hold any other insurance policy that will allow me to submit any claim in relation to this accident.
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