Car Rental Insurance Claim Form For 4×4 Self Drive Uganda, Car Hire Protection

4×4 Self Drive Uganda uses a UAP insurance company to insure its vehicles and in case of an Accident the renter should download and fill this form

UAP Insurance Uganda Ltd.

1 Kimathi Avenue, P.O Box 7185, Tel:0414 – 332 700
Fax: 0414 – 256 388, Kampala, Uganda. Email: uap@uapinsurance.co.ug. Website: www.gapinsurance.co.ug.

MOTOR ACCIDENT CLAIM FORM

IMPORTANT NOTICE

  1. No liability is admitted by the issue of this form
  2. Neither owner nor driver may admit fault or liability for this accident
  3. Do not answer communications about this accident. Direct these to the Insurance Company for action
  4. All questions on this form must be answered
  5. Repairs must not be authorized without prior authority of the Insurance Company

Insurers Claim No: …………………………………. Brokers Ref No: ……………………………………….

INSURED Name…………………………………….. ……..Tel No………………………
Address………………………………………………………………………….
Email Address …………………………………………………………………………Business/Occupation……………………………………………………………
policy number number Number……………………………Expiry Date……………………………….Name of hire purchase or finance Company……………………………………
vehicle Makemake Make & model …………………………..HP/CC……………………………..Reg. No. of Vehicle………………..Carrying Capacity………………………Reg. No. Trailer……………………. Carrying Capacity……………….…….. Name and Address of Owner……………………………………………………
estate State the exact purpose for which the vehicle was being used at the time of the accident………………………………………………………………………….
…………………………………………………………………………………..
…………………………………………………………………………………
COMMERCIAL Description of goods being carried……………………………………………..

 

 

VEHICLES Name of the owner of goods……………………… Was a trailer attached?……… Weight of load on (a) vehicle ………………(b) Trailer(s)…………………….
drivername Name …………………………… Occupation………………… Age…………
Address………………………………………………………………………….
Driving License No……………………………. Date of issue……………… Is he employed by you?…… How long has he been in your service?………….. Was he driving with your permission?………… How long has he been driving motor vehicles?………………………….

Was he in any way to blame for the accident?……. Did he admit liability?……

Has he had any previous accidents?…………………. If so how many, and

approximate dates……………………………………………………………….

Has he any conviction for any offence in connection with any motor vehicle or any

charges pending?…………………………………………………………

If so, give details including dates………………………………………………

…………………………………………………………………………………..

Does he hold a full or provisional license to drive this vehicle?………………

accident database Date ……………………….. Time………a.m/p.m Place……………………Type of road surface ………………. Visibility……………. Wet or Dry?……. What lights were showing on your vehicles?………………………………… What warning did your driver give?……………………………………………

Estimated speed before accident……………Weather condition.……………

Did the police take particulars?…………… If so, give the constable’s number

station…………………………………………………………………………

To which police station was the accident reported?…………………… Please quote

the police reference number……………………………………………

Attach copy notice of intended prosecution if any.

 

 

 

PLAN OFACCIDENT Draw sketch (stating approximate measurements) showing the position of vehicles and persons concerned and the direction in which they were travelling. Also, show the type and position of traffic signs, skid marks pedestrian crossings and any other relevant information.
STATEMENT BY DRIVER Signature of driver…………………………………………………
STATEMENT BY OWNER OR INSURED

 

 

DAMAGE TOINSUREDVEHICLE State briefly apparent damage…………………………………………………………………………………………………………………………………….. (In all cases where your vehicle is damaged you are entitled to claim under your policy, please send at once to the Company an estimate of repairs)

Repair’s name and address………………………………………………………

…………………………………….Tel No…………………………………….

Is the vehicle still in use? ……………………..When and where can it be
inspected?……………………………………………………………………….
OTHER VEHICLE/INVOLVED &PROPERTY

DAMAGED

“COMPLETE IN CASE OF THIRD PARTY CLAIM”
1. Name and address of driver of third party vehicle/s………………………………
………………………………………………………………………………….
2. Reg. No/s………………………………………………………………………….3. Name of insurer/s…………………………………………………………………4. Other property damaged………………………………………………………….
PERSONSINJURED Name and address relationship to relationship to relationship to Relationshipto the insured If driver orpassengerReg. No. ofvehicle Nature of injuries
INDEPENDENTWITNESS Name Address
PASSENGERS IN YOUR VEHICLE Name                                                 Address
I Declare that these particulars are true and correct and undertake to forward immediately (and unanswered any correspondence relating to this accident)Date…………….. 20………..     Signature of Insured……………………….