Fill and Sign the Notice to Users of This Form There is No All Inclusive Purchase and Sale or

Niko Insurance (Tanzania) Limited th PPF HOUSE, 8 Floor, Morogoro Road / Samora Avenue; Tel: +255 22 2120188; Fax: +255 22 2120193; E-mail: info@nikoinsurance.co.tz Website: www.nikoinsurance.co.tz MOTOR ACCIDENT REPORT FORM (Delete section not applicable) INSURED Name: Postal Address Tel No.: ___________________________________________________________________________________________ E-mail Address Occupation Fax No.: Policy No.: Make VEHICLE _______________ If vehicle subject to Hire Purchase, Credit or Leasing agreement, state name and Address of Finance Company Registration Chassis No. Engine No. Value Gross Carrying capacity HP/CC: Model and Year Kilometres Completed Date of purchase and price paid DAMAGE Damage to own vehicle Estimate for repairs or attach quotation Repair’s name, address and telephone number Where can inspected? Full Name your damaged vehicle be Address Phone No. Occupation and Date of Birth DRIVER Driving Licence No. Date Place Class Full/Learner State fully the purpose for which the vehicle was being used Was he/she driving with your permission? Was he/she in your employ? Has he/she any motor Insurance on own car? If yes, state Policy No. and Company Details of any convictions for motoring offences Has licence ever been endorsed? Has he/she any physical defects? PASS ENG ERS Details of previous accidents Name PASSENGERS Address Injury IN INSURED VEHICLE For what purpose were they carried? Are they employees? Registration No. Make Name and address of Owner and Driver OTHER PARTY DAMAGE TO OTHER VEHICLES Name and Address of Owner DAMAGE TO PROPERTY OTHER THAN VEHICLES Name of Injured Details of damage Details of damage Relationship to accident e.g. Driver, Passenger Details of Injuries Name of applicable PERSONAL INJURIES (OTHER THAN IN INSURED VEHICLES) WITNESS Name, Address and Phone No. Name, Address and Phone No. Date, time place of theft THEFT Was the vehicle left locked? Who is now in possession of the keys Police station and reference No. Vehicle, engine and chassis No. Colour of Vehicle If accessories stolen, provide full details Date, time place ACCIDENT Speed Before accident (a) Weather conditions (b) Visibility (a) Road surface (b) Width of road (a) Which vehicle lights were on? (b) Street lighting Was any warning given by you, e.g. hooting, indicator etc? (a) (b) (a) (b) (a) (b) Name of Police/Traffic Officer who recorded details of Accident Police Station and Reference No. Police Details Was driver tested for alcohol or drugs? DESCRIPTION OF ACCIDENT kph Moment of impact Result of Test Kph Hospital if Who in your opinion was to blame and why? SKETCH OF ACCIDENT (If necessary use separate page) Please show clearly the point of impact and indicate the direction of travel by arrows. Give details of any road safety signs or warning signs in vicinity of scene of accident LICENCE INSPECTION I have inspected the driver’s licence as shown Current Driving Licence No.:……………………………………………………………. Signature……………………………........... Valid for classes…………………………………………………………………………. Date of Expiry…………………………………………………………………………… Date of issue of 1st Licence and No……………………………………………………… Place of Issue…………………………………………………………………………….. Endorsement with Dates…………………………………………………………………. Type of Vehicle Driven at the Time of Accident………………………………………... Capacity………………………………........ Company Representative/Broker/Agent DECLARATION We hereby declare the foregoing particulars to be true in every respect (Signature of Driver)…………………………………………………………………….. Date………………………………………… Signature of Insured…………………………….. Capacity…………………………….. Date………………………………………… N.B. IT IS IMPORTANT THAT YOU NOTIFY THE INSURERS IMMEDIATELY YOU BECOME AWARE OF ANY IMPENDING PROSECUTION, INQUEST OR DEMAND.