Av. Kenneth Kaunda, 518, Maputo
mcs@mcs.co.mz
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Home page
MCS
Personal
Car
Health
Personal Accidents
Travel
Family Protection
Multi-risk and home
Corporate
Car
Health
Personal Accidents
Industry and Commerce Multi-Risk
Travel
School Personal Accidents
Documents
Documents
Claim
Branches
Contacts
News
FAQ’s
MOÇAMBIQUE COMPANHIA DE SEGUROS
CAR ACCIDENT REPORT
1. INSURED
2. DRIVER
Are you the usual driver of the vehicle?
Yes
No
3. DETAILED DESCRIPTION OF THE ACCIDENT
*
Indicate how fast your vehicle was going:
*
10. The driver of the other vehicle, as well as the owner of the property hit, or any of the injured, is:
Relative
Partner
Employee
1. Participant’s Status
Insured
Third Party
Broker
If you selected
Third Party
or
Broker
, please fill in the information below
Full Name
Contact
Phone
Email
2. Insured Person and Policy
Name
Policy number
3. Date and Time of the Incident
Date of the Accident
Time
Hours
Minutes
AM
PM
4. LOCATION (Road, locality, and district)
Checkbox
Were there any INJURIES, even minor ones?
Were there any Material Damages, other than those caused to vehicles A and B?
7. WITNESSES, Names, addresses, and phone numbers
VEHICLE A
VEHICLE A
8. INSURED
8. INSURED
Surname(s) and First Name(s)
Surname(s) and First Name(s)
Street Address
Street Address
Phone
Phone
Occupation
Occupation
7. VEHICLE
7. VEHICLE
Make and Model
Make and Model
Registration Number (or Engine Number)
Registration Number (or Engine Number)
Mozambique Insurance Company
Other Company
Policy No. (or Temporary Certificate)
Policy No. (or Temporary Certificate)
Policy No. (or Temporary Certificate)
Policy No. (or Temporary Certificate)
9. DRIVER
9. DRIVER
Surname(s) and First Name(s)
Surname(s) and First Name(s)
Street Address
Street Address
Phone
Phone
Occupation
Occupation
Age
Age
Driving License No.
Driving License No.
Category
Category
Valid from/to
Valid from/to
10. Indicate, using the options below, the point of initial impact.
10. Indicate, using the options below, the point of initial impact.
Front part
Rear part
Left side
Right side
Headlight
Mirrors
No damage
Other
Front part
Rear part
Left side
Right side
Headlight
Mirrors
No damage
Other
11. Visible Damages
11. Visible Damages
Front part
Rear part
Left side
Right side
Headlight
Mirrors
No damage
Other
Front part
Rear part
Left side
Right side
Headlight
Mirrors
No damage
Other
12. CIRCUMSTANCES OF THE ACCIDENT
12. CIRCUMSTANCES OF THE ACCIDENT
It was parked
It was leaving the parking lot
It was about to park
It was coming out of a private parking lot or a private driveway
It was entering a parking lot, private place or private road
It was entering a traffic circle or turning square
It was driving on a traffic circle or turning square
It crashed into the back of another vehicle traveling in the same direction and same queue
It was driving in the same direction but in a different queue
It was changing queue
It was overtaking
It was turning left
It was turning right
It was going backwards
It was driving on the part of the road reserved for oncoming traffic
It was coming from the left (at a crossroads or junction)
Didn't respect a signal to give priority
It was parked
It was leaving the parking lot
It was about to park
It was coming out of a private parking lot or a private driveway
It was entering a parking lot, private place or private road
It was entering a traffic circle or turning square
It was driving on a traffic circle or turning square
It crashed into the back of another vehicle traveling in the same direction and same queue
It was driving in the same direction but in a different queue
It was changing queue
It was overtaking
It was turning left
It was turning right
It was going backwards
It was driving on the part of the road reserved for oncoming traffic
It was coming from the left (at a crossroads or junction)
Didn't respect a signal to give priority
13. Regular Driver
Radio
Yes
Not
Documents Required for Claim Submission:
Copy of ID
Copy of Driving License
Copy of Ownership Title
Copy of Vehicle Registration Certificate
Police Report Number
Two Estimates (quotations)
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14. Detailed Description of the Accident
15. Declaration
The information provided has been given accurately, in good faith, and truthfully, and I assume full responsibility for it.
I authorize the Insurance Company to collect additional personal data from public authorities, specialized companies, and other economic entities in order to confirm or supplement the information necessary for managing the contractual relationship. Any omissions, inaccuracies, or falsehoods in providing information are the responsibility of the client. Access to the personal data provided will be granted under absolute confidentiality, provided it is compatible with the purpose for which the data was collected.
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