Third Party Accident Form

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1 Step 1
Third Party Vehicle Owner Details
Owner's Name
Owner's Address
Cellphone
Homephone
Third Party Vehicle Details
Vehicle Registration No.
Make and Model of Vehiclefor ex.: Hyundai Santa Fe
Color of Vehicle
DisplacementHP or CC
Third Party Vehicle Driver Details
Driver's Name
Driver's Address
Driver's Permit No.
Class
Issue Date
date_range
Expiry Date
date_range
Insurance Company
Policy & Certificate No.
Description of Damages and your estimate of the cost of repairsSeparate in multiple lines
0 / 500
Trinre Insured Details
Policy Holder Name
Address
Cellphone
Homephone
Trinre Insured Coverage Details (if known)
Policy No.
Issue Date
date_range
Expiry Date
date_range
Insured Vehicle Details
Vehicle Registration No.
Make and Model of Vehiclefor ex.: Hyundai Santa Fe
Insured Driver Details
Name
Mailing Address
Cellphone
Homephone
Driver's Permit No.
Class
Issue Date
date_range
Expiry Date
date_range
Accident Details
Loss Date
date_range
Time
access_time
Location
Insured VehicleDirection of travel
Third Party VehicleDirection of travel
Speed (kmph)At the time of accident
Condition of road
Was horn sounded?
Was visibility good?
Was accident reported to police?
Date of Notification
date_range
Station
Receipt No.
Name of Officer
Rank of Officer
Officer Badge No.
Damages to third party vehicle
Description of DamagesSeparate in multiple lines
0 / 500
Was estimate prepared?
Name of Repairer
Cost
Where can vehicle be inspected?
Was any person injured in accident?
Passengers in Trinre Insured Vehicle
Name
Age
Address
Details of Injury SustainedIf any
Physician or HospitalIf any
Passengers in Third Party Vehicle
Name
Age
Address
Details of Injury SustainedIf any
Physician or HospitalIf any
Draw sketch of accident


Please see the sample sketch shown above, using this as a reference, please try to mark the location your vehicle, the location of third party vehicle, pedestrians & other people concerned in this accident claim.

Please follow the steps below to mark positions on the blueprint and re-upload it for us to better evaluate your case.

Instructions

  1. Download the sketch blueprint here.
  2. You can sketch using your touchscreen device, or print a copy & do the sketching.
  3. If you do this on a device, you can save after sketching or if you printed a copy, just sketch on it with a pen, then take a photo of it.
  4. Upload it using the button below.

You're done.

Upload Documents
cloud_uploadUpload
In your opinion who was at fault?
Did such a person admit responsibility?
Give full details of accident
Details
0 / 1000

​Declaration *

I/We declare that the above statements and facts are true and that I/ we have not withheld any information within my/ our knowledge connected with the claim.

I agree that in such an eventuality the company can deny liability for all claims arising out of this accident.

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