Claims Form – Insure All The Way

I/We (the insured/beneficiary) , of hereby declare that all information provided by me/us pertaining to the claim below has been wholly and honestly supplied to INSURE ALL THE WAY,

I/We undertake that all documents provided supporting this claim are authentic and complete.

YOUR DETAILS

Name *

Vehicle Registration Number *

Email Address *

Telephone Number *

Policy Number *

Driver's Details (Complete if not same as policy holder)

Driver's Full Name

Address *

Phone Number *

Driver's relationship to insured *

Does he/she hold a license?YesNo(If yes, provide a copy along with this phone)

License evidence *

No file chosen

Was there any admission of responsibility for the accident?YesNo

Give details

DETAILS OF ACCIDENT/THEFT

Fire Damage *YesNo

Third Party Injury/Death *YesNo

Date of loss *

Vehicle Registration Number *

Location of Theft/Accident *

Time of Theft/Accident *

Narration of Accident *

THIRD PARTY DETAILS (Please complete the following if other vehicles were involved or other property damaged)

Name of the third party vehicle owner/driver *

Vehicle make/model *

Vehicle Registration Number *

Describe the damage to the third party vehicle/property *

Phone Number *

Email Address *

Insurance details (Provide evidence/certificate) *

Certificate evidence *

No file chosen

Home/ office address *

WITNESSES, INCLUDING ALL YOUR PASSENGERS

Witness 1

Name *

Mobile Number *

Address *

Where was the witness when the accident occurred *

I/We declare the above information to be true and I/we hereby authorize INSURE ALL THE WAY and/or their Legal representatives to deal with all matters arising from this loss at their discretion and if they deem it expedient, to admit liability and/or negligence on the part of myself/our servant or agents.

Date *

DATA PRIVACY POLICY

In line with the Nigeria Data Protection Regulation, your consent is required before processing your data for official use. Insure All The Way requires your data for the purpose of processing your claim with the company. This may include your name, address, means of identification, email address and such other information relevant to the creation and renewal of your Insurance Policy(cies) with Insure All The Way. Your information may also be required to provide product related services, cross selling, discretionary transfers, regulatory, governmental, tax, and legal, compliance, marketing and communication requirements.
At all times, you have the right to request, rectify or update your data. You may also authorize Insure All The Way to delete your data and restrict the processing of your data at the expiration your Insurance
By signing below, you agree to our full data privacy policy on Insurealltheway.ng/privacy policy. For more enquires please contact:
info@insurealltheway.ng
Kindly provide your consent below:
I hereby consent to the collection, use and transfer, in electronic form or otherwise, of my personal data, for the purpose of processing your claim with Insure All The Way, fulfilling necessary regulatory and other operational requirements.

Date *

Motor Insurance Claims Form

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