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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:

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