ACCIDENT REPORT FORM

JNSHC does not admit liability by the issuance of this form,

TO AVOID DELAY AND INCONVENIENCE PLEASE ANSWER ALL QUESTIONS FULLY

This form should not be taken as an admission of liability.
It is intended to provide information to assist in the handling of your claim.
Please be aware that there is no automatic right to compensation.

DETAILS OF INSURED

Name of Insured:

Insured's Email Address:

Address of Insured:

Name of Insurer:

Date of Accident/Incident:

Policy Details:

Tel Nos.: (H)

Mobile:

Office:

DETAILS OF DRIVER

Driver's Name:

Driver's Address:

No. and Type of Driver's Licence:

Date of Birth:

Driver's Occupation:

Expiry Date of Current Licence:

PARTICULARS OF MOTOR VEHICLE CONCERNED

Make of Vehicle:

Year of Make:

Type of Body:

Reg. Letter and No.

PARTICULARS OF DAMAGE TO INSURED'S VEHICLE

Full Details of Damage:

Estimated Cost of Repairs J$:

Is your vehicle still in use?

Yes No

Can the vehicle be inspected?

Yes No

Was the vehicle removed by wrecker?

Yes No

PARTICULARS OF ACCIDENT

Date of Accident:

Place Weather/Visibility:

Condition of road surface:

Time:

Estimated speed of your vehicle:

Give full details of how Accident/Loss or Damage occurred:

Supporting Documents

images and Documents Supported

Driver's Signature

Was Accident reported to Police?

Yes No

Which Police Station?

PARTICULARS OF OCCUPANTS OF INSURED

How many persons were in the vehicle?

Were the occupants injured?

Yes No

Were the passengers wearing seat belts?

Yes No

Passenger 1 Name:

Passenger 2 Name:

Passenger 3 Name:

Passenger 4 Name:

Passenger 1 Address

Passenger 2 Address

Passenger 3 Address

Passenger 4 Address

Relationship with the Insured

Nature of Injury hospital attended (if any)

WITNESSES

It is the utmost importance always to obtain the names and addresses of witnesses

Witness Name 1

Witness Name 2

Witness Name 3

Witness 1 Number

Witness 2 Number

Witness 3 Number

Witness 1 Address

Witness 2 Address

Witness 3 Address

PARTICULARS OF PROPERTY INVOLVED IN ACCIDENT

Full Details of damage to vehicle or other property (such as walls, fences, signs etc.)

I/We declare that the information given in this form is true and correct to the best of my/our knowledge/belief.

I/We further declare that the statements above can be relied upon in the contemplation of litigation proceedings which may arise.

Date

Owner's Signature

Driver's Signature

Accidents Forms

ACCIDENT REPORT FORM

JNSHC does not admit liability by the issuance of this form,

TO AVOID DELAY AND INCONVENIENCE PLEASE ANSWER ALL QUESTIONS FULLY

DETAILS OF INSURED

DETAILS OF DRIVER

PARTICULARS OF MOTOR VEHICLE CONCERNED

PARTICULARS OF DAMAGE TO INSURED'S VEHICLE

PARTICULARS OF OCCUPANTS OF INSURED

WITNESSES

PARTICULARS OF PROPERTY INVOLVED IN ACCIDENT

About the JNSH

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