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Accident Claim Form

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JNSHC DOES NOT ADMIT LIABILITY BY THE ISSUANCE OF THIS FORM.

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.

TO AVOID DELAY AND INCONVENIENCE PLEASE ANSWER ALL QUESTIONS FULLY

 

Particulars of Insured
Enter first name of insured/owner
Enter last name of insured/owner
Enter the name of the insurance company the policy is with.
Enter your insurance policy number
Enter your 10+ digit phone number
Enter your 10+ digit phone number
Enter your 10+ digit phone number
Particulars of Driver
Enter driver's first name
Enter driver's last name
Select your date of birth
Enter driver's license number
Particulars of Vehicle
Select the make of your vehicle
Enter your vehicle model (e.g. CRV, Probox, Corolla, Prado)
Enter your vehicle identification number
Enter your vehicle registration number
Particulars of Accident
Select the date & time of the accident
Enter the estimated speed of your vehicle in km/h
Select Police station accident was reported to
Give full details of how Accident/Loss or Damage occurred
Particulars of Property Involved in Accident
Full Details of damage to vehicle or other property (such as walls, fences, signs etc.)
 
Particulars of Damage to Vehicle
Give full details of damage to vehicle
Enter the estimated cost of repairs in $JMD
Particulars of Passengers in Vehicle
Passenger Full Name Passenger Address Relationship with the Insured Nature of Passenger Injury Hospital attended Weight
Enter Passenger Full Name
Enter Passenger Address
Enter Relationship with the Insured
Enter Nature of Passenger Injury
Enter Hospital attended
more items
Particulars of Witnesses
Witness Full Name Witness Address Witness Phone Number Weight
Enter Witness Full Name
Enter Witness Address
Enter Witness Phone Number
more items
Declaration & Signature
Statement of Declaration

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.

Check this box to confirm your agreement with the declarations above
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