CIA: MOTOR RELATED CLAIM

Part A: personal and claimant's details (compulsory)

Full Name *

Next Of Kin *

Relationship *

Contact *

Id No./ Company Certificate Of Registration Number: *

Kindly attach a certified copy *

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Physical Adress: *

Postal Address: *

Postal Code *

City: *

Telephone No: *

Enter your email address *

Claim Details

Name Of Insurance Company Against Which You Are Lodging Your Claim: *

Claim Number: *

Policy Number: *

Claim Amount: *

Amount Received: *

Outstanding Balance: *

Discharge Voucher Available? *

Yes

No

(If yes kindly attach a certified copy) *

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Court Award Available? *

Yes

No

(If yes kindly attach a duly stamped certified copy) *

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Category C1 A: Motor Related Claims

REQUIREMENTS
Attachment of the following certified copies of documents is required for the stated entities:

Original Discharge Voucher
Court Judgment/ Award (For third party liability, any other claims subject to court process).
Letter of Administration
Copy of police abstract.
Copy of ID or Passport for individual claimants.
Copy of certificate of incorporation/registration or incorporation certificates for Companies Corporations and other unincorporated entities.
Copy of logbook of the Motor vehicle.
Copy of death certificate or official death notification or burial permit in respect of claims for deceased persons.
Copy of PIN certificate.
Any other proof of claims e.g., Receipts of payment.

NB: False or Fraudulent claims, as regards to amount or otherwise will attract to criminal proceedings against an applicant

Copy of ID or Passport for individual claimants *

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Both Sides

Copy of PIN certificate *

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Copy of logbook of the Motor vehicle *

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Copy of police abstract *

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Any other proof of claims e.g., Receipts of payment. *

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Motor Related Claims

Please select the appropriate class of motor related claim: *

Own Damage (Including Fire or Theft)

Third Party Property Damage

Third Party Injuries/Death

Details For Motor Related Claims (Compulsory)

Name Of Insured Person (Policyholder) *

Vehicle Registration No *

Vehicle Body Type (Saloon, Minibus, Van Etc.) *

Date Of Accident *

Only For Third Party Claimants

For Injury: Name Of Injured Person: *

Case Number *

For Death Name Of The Deceased Person *

Attach Certified Copy Of Death Certificate *

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State Your Relationship To The Deceased: *

Name Of The Administrator Of Estate Of The Deceased *

Kindly attach a certified copy of the letter of administration *

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Case Number *

Part A: personal and claimant's details (compulsory)

Claim Details

Category C1 A: Motor Related Claims

Motor Related Claims

Details For Motor Related Claims (Compulsory)

Only For Third Party Claimants

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