Declaration

I/We warrant the truth of the answers to the questions below and I/we declare that no information has been withheld and that the amount claimed represents my/our loss arising from the stated occurrence. By submitting this claim I declare herewith that I am the Insured in terms of this policy.

[* Indicates required fields]

Policy number:*

Surname or Company Name:

Initials:

Insured's ID Number:

Insured's e-mail address:

Phone number - Home:

Phone number - Work:

Cellphone number:

Date of the accident:

Time of the accident:

At what address did the accident occur?

Address line 2:

Address line 3:

City:

Police/Traffic Department where the accident was reported:

Date reported:

Police Crime/accident Register Ref No.:

Short Description of the accident:

For what purpose was the vehicle being used?

Details of the driver of the insured vehicle:

Driver of the vehicle at the time of the accident is the same person as the policy holder:

Surname:

Initials:

Title:

Relationship with insured (eg. self, child, friend, employee):

ID Number:

Driver's licence code:

Date issued:

Driving on Learner's Licence?

Yes no

Had the driver consumed alcohol prior to driving?

Yes No

Was a blood sample taken after the accident?

Yes No

If a blood sample was taken what was the result?

Make of the vehicle:

Year of Manufacture:

Registration of the vehicle:

Is the vehicle insured under any other policy?

Yes No

Name and address of the registered owner:

Registered owner of the vehicle is the same person as the policy holder:

Surname:

Initials:

Address line 1:

Address line 2:

Address line 3:

City:

Province:

Postal code:

Estimated cost of repairs:

Do you have a quote for the repairs to the vehicle?

If yes, by whom?

Phone number:

Address where the vehicle may be seen:Address line 1

Address line 2:

Address line 3:

City:

Were there any other parties involved?

Third party details (Damages to other people's property)

Surname:

Initials:

Phone number - Home:

Phone number - Work:

Cellphone number:

Address of third party:Address line 1

Address line 2:

Address line 3:

City:

Have any passengers in your vehicle sustained injuries?

Yes No

Make of other vehicle:

Registration number of other vehicle:

Eye witness?

Yes No

Surname:

Initials:

Phone number - Home:

Cellphone number:

Phone number - Work:

I certify that the above information is correct.

(Mark box)

I certify that I agree to the Declaration.*

(Mark box)

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Namsure – gaining momentum!
Namsure recently secured the prestigious City of Windhoek account after successfully tendering for it.
Namsure director Hennie Köhne has experience of managing similar large accounts and this will ensure that the City of Windhoek receives the levels of service and expertise that they can expect.

Commercial insurance
Namsure offers a wide range of commercial insurance solutions.
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Personal insurance
Property insurance. Liability and legal-aid insurance.
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Professional indemnity
A professional indemnity plan provides cover for claims against policyholders due to their professional negligence.
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Marine
Marine cargo and marine hull coverage.
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