Form Seguro automovel

1. Participant’s Status

InsuredThird PartyBroker

If you selected Third Party or Broker, please fill in the information below

Full Name

Contact

Phone

2. Insured Person and Policy

Name

Policy number

3. Date and Time of the Incident

Date of the Accident

Hours

Minutes

4. LOCATION (Road, locality, and district)

5. Were there any INJURIES, even minor ones?6. Were there any Material Damages, other than those caused to vehicles A and B?

7. WITNESSES, Names, addresses, and phone numbers

VEHICLE A

VEHICLE B

8. INSURED

8. THIRD

Surname(s) and First Name(s)

Street Address

Phone

Occupation

9. VEHICLE

Make and Model

Registration Number (or Engine Number)

10. Mozambique Insurance Company

10. Other Company

Policy No. (or Temporary Certificate)

11. DRIVER

Surname(s) and First Name(s)

Street Address

Phone

Occupation

Age

Driving License No.

12. Indicate, using the options below, the point of initial impact.

13. Visible Damages

14. CIRCUMSTANCES OF THE ACCIDENT

15. Regular Driver

YesNot

16. Documents Required for Claim Submission:

Submit Documents

17. Detailed Description of the Accident

18. 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.

MOÇAMBIQUE COMPANHIA DE SEGUROS

CAR ACCIDENT REPORT

1. Participant’s Status

2. Insured Person and Policy

3. Date and Time of the Incident

4. LOCATION (Road, locality, and district)

7. WITNESSES, Names, addresses, and phone numbers

VEHICLE A

VEHICLE B

8. INSURED

8. THIRD

9. VEHICLE

9. VEHICLE

10. Mozambique Insurance Company

10. Other Company

11. DRIVER

11. DRIVER

12. Indicate, using the options below, the point of initial impact.

12. Indicate, using the options below, the point of initial impact.

13. Visible Damages

13. Visible Damages

14. CIRCUMSTANCES OF THE ACCIDENT

14. CIRCUMSTANCES OF THE ACCIDENT

15. Regular Driver

16. Documents Required for Claim Submission:

17. Detailed Description of the Accident

18. Declaration