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Motor Claim
Please complete the form for your Motor claim
INSURED DETAILS
Policy Number
*
VAT Registration Number
Name
ID Number
*
Occupation
*
Phone
*
Email Address
*
Plot Number
Ward /Locality
City
Postal Address
VEHICLE
If vehicle subject to Hire Purchase, Credit or Leasing Agreement, state name and address of Finance Company
In whose name is the vehicle registered?
*
Registration Number
*
Year Of Manufacture
*
Car Model
*
Car Make
*
Tare
*
Tare Gross Vehicle Mass
*
Kilometres completed
*
Price Paid
*
Accident Date (if applicable)
*
Place
*
Speed
*
Weather
*
Visibility
*
Road Surface
*
DAMAGE
Damage to own vehicle
Estimate for repairs or attach quotation
Repairer’s name
Address
Telephone no.
Where can your damaged vehicle be inspected?
Requirement Checkist
*
Police report
Copy of driver’s license
Registration book
Two (2) quotations
Photos of accident
Upload ALL Documents selected above
*
Drag and Drop (or)
Choose Files
File types allowed (Jpg, Png, PDF, Doc, Docx, Zip)
DRIVER
State fully the purpose for which the vehicle was being used
Full Name
Occupation
Address
ID No.
Telephone no.
Driving Licence (Attach copy)
*
Drag and Drop (or)
Choose Files
File types allowed (Jpg, Png, PDF, Doc, Docx, Zip)
Licence Number
Validity Period
Place
Class
Full Learner
Was he/she driving with your permission?
YES
NO
Was he/she in your employ?
YES
NO
Is he/she the owner of another vehicle?
YES
NO
If yes, give name of Insurer and policy number
YES
NO
Details of previous accidents
Has licence ever been endorsed?
Select
YES
NO
Has he/she have any physical defects?
Select
YES
NO
Details of any convictions for motoring offences
PASSENGERS (Insured Vehicle)
State fully the purpose for which the vehicle was being used
Full Name
Address
Injury
Full Name
Address
Injury
Full Name
Address
Injury
Full Name
Address
Injury
For what purpose were they carried?
Are they employees?
Select
YES
NO
OTHER PARTY
OTHER VEHICLES
Registration Number
Make
Name and Address of Owner and Driver
Details of damage
Registration Number
Make
Name and Address of Owner and Driver
Details of damage
Registration Number
Make
Name and Address of Owner and Driver
Details of damage
Registration Number
Make
Name and Address of Owner and Driver
Details of damage
PROPERTY OTHER THAN VEHICLES
Name of owner
Address
Details of damage
Name of owner
Address
Details of damage
PERSONAL INJURIES (OTHER THAN IN INSURED VEHICLE)
Name of injured
Relationship to accident
Details of injuries
Name of Hospital (if applicable)
Name of injured
Relationship to accident
Details of injuries
Name of Hospital (if applicable)
Name of injured
Relationship to accident
Details of injuries
Name of Hospital (if applicable)
Name of injured
Relationship to accident
Details of injuries
Name of Hospital (if applicable)
WITNESS
Name
Address
Telephone No.
Name
Address
Telephone No.
ACCIDENT
Place where accident occurred
Date
Time
Hours
Minutes
Requirement Checkist
*
Police report
Copy of driver’s license
Registration book
Two (2) quotations
Photos of accident
Upload ALL Documents selected above
*
Drag and Drop (or)
Choose Files
File types allowed (Jpg, Png, PDF, Doc, Docx, Zip)
SPEED >
Before accident
Moment of impact
a) Weather condition? b) Visibility?
Was any warning given by you,
YES
NO
e.g. hooting, indicator, etc.?
a) Which vehicle lights were on? b) Street lighting
POLICE
Name of police/traffic officer who recorded details of accident »
Police Ref. no. / Police Report
Station Reported
Date reported
Requirement Checkist
*
Police report
Copy of driver’s license
Registration book
Two (2) quotations
Photos of accident
Upload ALL Documents selected above
*
Drag and Drop (or)
Choose Files
File types allowed (Jpg, Png, PDF, Doc, Docx, Zip)
DRIVER
Was driver tested for alcohol or drugs?
YES
NO
Description of Accident
SKETCH OF ACCIDENT (if neccesary use separate page)
*
Drag and Drop (or)
Choose Files
Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety signs or warning signs in vicinity of scene of accident
LICENCE INSPECTED
*
Drag and Drop (or)
Choose Files
Please attach copies of driver’s licence and page 1 of driver’s identity document
DECLARATION
*
We hereby declare the aforegoing particulars to be true and complete in every respect. By signing below, I agree and voluntarily consent to Sesiro's processing of the provided Information for the purposes of processing my claim, and I give Sesiro permission to do so, and any personal data (including sensitive personal data) will be processed in accordance with Sesiro's privacy policy available on its website, and I further understand that I am free to withdraw my consent on written notice to Sesiro, on legitimate grounds which are reasonable and compelling. I agree that the Information may be disclosed by Sesiro to third parties, including Sesiro's affiliates, service providers and associates (some of which may be located outside of Botswana).
SUBMIT
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