£000-10-05 (AS) NOTICE OF EFU Registered Office: 11/4, Saddar Road, 20. Box No. 44, Peshawar-25000 ACCIDENT FORM GENERAL eos fice: FU House, (MOTOR VEHICLE) MA. Jinnah Rood, Karochi-74000 INSURANGE 1: 2212471-20 Fax: 92-21-2310450 (icorpocted in Poison) Estalshed 1932 THIS FORM MUST BE RETURNED TO THE COMPANY IMMEDIATELY WITH ALL QUESTIONS FULLY ANSWERED WHETHER A CLAIM IS LIKELY TO ARISE OR NOT. The Company does not admit liability by the issue of this form. Please read this form through before filling in details. CLAIM NO.___ POLICY NO._______ EXPIRY DATE Name Tel. No. Occupation Address INSURED Cubic | Rogie Later | 1 For wha purpose was Vice bong ued? Makoancveur | cSnacty | andNombere” | 2 For what puose goneraly used? Engine No Chassis No, Colour Was a Taller etached? if Motor Cycle How many persons were in the Vehicle (1) Was Side car Attached? atthe time? (2) Was a Pilion Rider carried? PARTICULARS | OF VEHICLES. | Wasvétilen proper oe and conion CONCERNED IN tt°Goods Carrying Vehicle: ACCIDENT een Is policy holder the owmer ofthe Vehicle (1) State nature and approximate Weight of oad cared? Was the Vehicle being used withthe (2) Was a Taller attached? Owners knowiedge and consent?Name of Driver at time of Accident Age ‘Address of Driver Owner? _ —EEGS FeUNsT SSE Is Driver (Owner's Regular Paid Driver? Owners Relative or Friend? No. and Date of Issue and Expiry of Licence Has it been endorsed? If so give particulars DRIVER Hes Driver, Previously ton Involved an Accidene? if Paid Driver, how long has he been in your employment? Was the Driver, under te influence of alcohol er drugs at he time of the accident? Date, Time Place Estimated Speed of your Vehicle Mies per Hour Give full description of accident. Loss or Breakdown, at STATE HOW ACCIDENT LOSS OR BREAKDOWN OCCURRED ‘Give names and addresses of allwinesses of Accident- Passengers WITNESSES ne Itis most important that Names and | independent Addresses of all | ‘Witnesses independent : Witneecos of an | fWinesss names not taken give reason Accident should be | Oi @Polceman winess Accigent or take pariclas? obtained, whether | Policeman's No. the Driver considers | as any statement, ast faut, made by winesses or Drivers at the tne? himself to blame or not was the matter reported to the Police? If so, give name and adress of Police Station and state what action, if any, has ors being taken not reported to the Police, the reasons for the same,_—— eee PARTICULARS OF DAMAGE OF INJURY TO THIRD PARTY (PROPERTY OR PERSONS) ig es ee oe eS ae ‘Adress Full extent of Personal injuries or Damage to Property {f any injured person has been removed to hospital or medically attended, give name and address of the Hospital or Doctor Has notice of any Claim been to you? Insurer: Policy No.. ‘Admit no labilty in any crcurnstances but despatch to the Company forthwith and unanswered any writen ‘communications which may have been received. PARTICULARS OF DAMAGE TO INSURED VEHICLE UN aria f Dears aslo rece vee not oct ree) Where the Vehicles can be Inspected: Estimated cost of Re In the event of damage to tyres as a result of the Accident sate: When purchased______ Approximate Mileage done has it been Retreaded?______ When An estimate of cost of repairs should immediatoly be obtained and forwarded to the Company THEFT ALSO TO BE FILLED IN, IN CASE OF THEFT. If Loss occured while vehicle was standing in street, was it unattended? If 80, how long? lt Car was in garage, was forcible entry made, if so, in what manner? Have the Police been advised? If so, when and with what result? If no why not? Was any damage inflicted to the Car? Please state any further particular, if any FILA. and Final Police Investigation Report to be obtained and forwarded to the Company.Please make rough pian of the road inthe space reserved below itustating the positions of Vehicles and SKETCH Persons concemed atthe time of Accident. An arrow should indicate the direction in which they were moving | 's there any other Policy indemnitying your or the Driver in respect or this accident? | 80 the name of insurers, the Policy Number and the sum insured Declaration : '/We hereby declare the foregoing particulars to be true in every respect and claim under the Policy the amount of my/our loss. Dated Insured's Signature