ALLIANCE INSURANCE COMPANY (PVT) LIMITED

HARARE ADDRESS BULAWAYO ADDRESS

66 Ridgeway North, Borrowdale, Harare 7 Oaks Avenue, Suburbs, Bulawayo
P.O Box Bw 339, Borrowdale, Harare

Tel: +263 4 882060; +263 4 882150/56 Tel: +263 9 230683; +263 9 230651/3
Fax: +263 4 882229 Fax: +263 9 230689
Email : queries@aic.co.zw Email: queries@alliance.co.zw

MOTOR CLAIM FORM

PLEASE FURNISH ALL DETAILS USING THIS REPORT

INSURED: Name Farai chiduwa . Address 38 Helvtia IMPALI Shurugwi ..

Telephone No. Home 0777488458 ... Business . unki mines ..

*SHOULD THE COMPANY BELIABLE TO SETTLE THIS CLAIM PLEASE TICK THE APPLICABLE

1. DEPOSIT CHEQUE INTO: BANK stanibic .. ACCOUNT NO. 9140001502513 .. BRANCH Gweru ..

2. SEND CHEQUE VIA MY BROKERS

Make/Model Nissan Latio .. . Year 2007 .. . Reg No AEJ2598 .

Name of Owner Farai chiduwa .. ..

MOTOR Address 38 helvtia IMPALI Shurugwi .. .

VEHICLE
DETAILS For what purpose was vehicle being used private car

Name of Hire-Purchase Company,if any N/A Amount Outstanding . .

________________________________________________________________________________________________________________________________________________

Driver’s full name Farai chiduwa Age/Date of Birth 20/12/1973 Driver’s licence No
44140LM ..
DRIVER’S LICENCE
Date & Place of issue 09/10/2013 Gweru Endorsements Yes/No no .When
and why N/A

DATE Date of Accident 02/03/2025 ..Place of accident 68km peg Gweru _Chibi Road. Time 22:30 hrs
Time 22:30 hrs .. ..
TIME AND
PLACE OF ACCIDENT Describe weather conditions slightly mist . .

Description of road and its condition road good .

Who authorized use of Motor Vehicle? farai chiduwa .

DESCRIPTION Why? attending church night prayer . .

OF ACCIDENT
Speed? 60km/hra .. .. If object collided with was moving, what direction was it going? a donkey they they they
theywere four covered the oncoming lane and the lane I was driving with ... ...

Police station where report was made and IR OR TAB. NO. Gweru traffic ...

If matter was not reported to police, please advice reason reported .

4
Number of persons in Insured’s motor vehicle four ..

Farai chiduwa 38 helvtia IMPALI shurugwi 52 Self Indicate by X if

injured was:
Name Address Apparent Relationship to Occupant of Occupant of other car Pedestrian
Age Insured insured’s car
Letwin mukwaira 38 helvtia impali Wife Front seat N/A
Minashe chiduwa 38 helvetia Daughter Backseat N/A
Petros mupunga Dark city Churchmate Backseat

Nature and extent of injuries N/A . .

PERSONS If medical attention was rendered, give name of doctor N/A . ...
Page 1 of 3 2016/3 Motor Claim Form
INJURED
Where were the injured taken N/a . ...
N/a

Name of owner Farai chiduwa . .. Address . ..

DAMAGE TO Kind of property (if motor vehicle give make & year) Nissan Latio aej2598 .
.
PROPERTY OF
OTHERS Nature and extent of damage ..

Estimated cost of repair see attached . Has claim been made? . ...

Is claimant insured? . Claimant’s licence number . ...

panel Beaters Quotations
Name of Insurance Company Alliance .

IT IS IMPORTANT TO COMPLETE BOTH SIDES OF THIS REPORT FORM

Whenever possible please obtain names and addresses of witnesses, bystanders or persons in the immediate
NAMES AND vicinity who may have seen the accident or heard statements made by any of the persons involved.
ADDRESSES OF
WITNESSES NAMES ADDRESSES
(IMPORTANT)
.. ..

.. ..

DAMAGE TO Parts damaged and extent headlamp, bonnet and windscreen

.
MOTOR VEHICLE
OF INSURED Estimated cost of repairs .

Repairs should only commence with the Company’s consent.

Name of party who caused damage Address .

Is he insured? .. If so, name of company if known .

Where may automobile be seen

Driver’s Statement:

l was driving my vehicle as stated above i come a cross donkeys donkeys donkeys standing
and moving. In the road unattended without anyone to ask who is the Owner Owner

DRIVER’S
ACCOUNT OF
ACCIDENT OR
LOSS

Page 2 of 3 2016/3 Motor Claim Form

 Date 11/03/2025 Signature of Driver Fchiduwa

DIAGRAM OF
ACCIDENT

GIVE STREET NAMES, DIRECTION AND LOCATION OF OBJECTS CONCERNED

DECLARATION: I/We hereby declare that the above statements, facts, and documents are true and that I/we have not
withheld from the Company any information within my/our knowledge connected with the accident or loss.

Date .. Signature of Insured

Page 3 of 3 2016/3 Motor Claim Form