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

No liability is admitted by the issue of this form
Neither owner nor driver may admit fault or liability for this accident
Do not answer communications about this accident. Direct these to the Insurance Company for action
All questions on this form must be answered
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 OF_ACCIDENT	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………………………………………………………….
PERSONS_INJURED	Name and address relationship to relationship to relationship to	Relationshipto the insured	If driver orpassengerReg. No. ofvehicle	Nature of injuries

INDEPENDENT_WITNESS	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……………………….