13. Property (non vehicle) Damage: Give details of property damage sustained:
If any of the following documents are available you must supply them with this form: (a) estimate for repairs (b) engineers report (c) photographs of damaged property.
Note: An excess is applicable to MIBI Property (non vehicle) Damage Claims in certain specific circumstances. 14. Personal Injury: Give brief details of the injuries sustained:
Please supply the name and address of medical attendants. If a medical report is available you must supply it with this form.
15. Uninsured Losses: (E.g. Policy Excess) Give specific details:
Please furnish all documents supporting your uninsured losses claim.
SECTION C – CLAIMANT’S VEHICLE DETAILS:
16. Registration Number:
17. Make & Model of Vehicle:
18. Country of Registration:
19. Vehicle Owner:
20. Vehicle Driver (at time of accident):
21. Vehicle Insurer: (not broker)
22. Policy Number:
23. Cover Type: (please specify) Comprehensive
Third Party Fire & Theft
Third Party Only
Policy Expiry Date: