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MOTOR CLAIM FORM
IMPORTANT NOTICE
1. No liability under the policy is admitted by issue of this form
2. Neither owner nor driver must admit fault or liability for this accident
3. Donot answer any communication about this accident, but send them to the insurers for
consideration
All questions on this form must be answered
5S. Repairs must be authorized without prior authority of the insurer
POLICY HOLDER
names PRO INDUSTRIES PTE. FIR oF) AYOOS?
# ees. elt Counte Reasl,.Kele)o, Keto
Address. Menicbes. Buti ittog,
VEHICLE
Make & Model... LAMAAA...YEAM, PRA- ZAR RO M-ApxeP Co)
{attach copy of
vehicle oabook) | Reg. No of Vehicle... BP. FI.OE.. Reg, No of Traler
Description of goods being carried a S
Weight of load... co
Name ATAYONAA. “TIMES
dtuertzene) | Telephone no... OF 23GNSBAI.
alse. Se
rer | pate... 7-02-20 24 rine. -.2. 44.0.)
place... Kati kenny
Type of road surface NUM...
[oriver |
Occupation...
Estimated Speed before the accident.n0A}. e.g,
POLICE ‘oath
PARTICULARS | To which police station was the incident reported... MMabM lemme, .3!Nee—
an
(Attach police | if not, state the reasons for not reporting, “
report, iov and —$—
sketch)
UGANDA
ing, Bandai Rise Kampala Uganda
T +256 414 349659/60 mua.co.ug
MUA Insurance (Uganda) Ltd BRN 46373 3'*Floor, Red Stone Buil ‘STATEMENT BY
‘THE DRIVER
4 James Heyomba on tue dake t7 OE lomwy ¢
st yen fear ead FAAS dee shale 4 pedioa
lo MT ‘r Ww » Vhen Tux i
Se te riod dite $00 sped of O|
foke$h, nan ¢ seul iV kMiesnn PidrP.
mahinelaa uber EErT Knocked mua for hon\nol
eet ito Slamiege on Hee HE , Lt VS
apetacer C12 M7 Tine ealladl, € infovardet My
PENCE Ansk 2 Gti Rot Ugerota police webyfen}
do Guse cnet help ug Tne ome Ref)
‘STATEMENT BY
THE OWNER OF
VEHICLE
Rc Z informal by Cat] Qnol whilaP megego do
Mse Emily Namulinefy on Hee Sanne dow of
Rec Pent ‘Qnof elo sheree! Hee photas ote
Vehicle. my efsiveg wey clilialy veal
formu 5 ond Hue af acc\liand Ie
thre Neale mahinslrg pileup BH 6 Of)
My wequiG® Serie provide wamule motort
Lid neon estinabe rh 075,080 vn
tos clomoge epee, T have atachZot Hue
olong Wik photographs of Hee slemge. oy
DAMAGETO | State briefiy apparent damages... Pear... Bump OE NEL... OivP@S
INSURED ;
VeHicle AenahSy Reseed brated B.S G2 Sehles Aaa
{Attach at least two repair quotes)
OTHER
venics; | OBH 6 EET Comesa food trohubsies tyef,)
PERSONS :
invowveo i
INDEPENDENT ca Mme?
rite Kikees!
wiresss | Hes aoe te.
{DECLARE THAT THESE
MUA Insurance (Uganda) ltd BRN 46373* (“37
O10 ae se
ia we Ene ug tr toe tangas noe
A
7 #256 414 349659/60 mua.co.ug
