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Our aim is not only to pay your claims but also to protect and assist you. For this purpose, it is indispensable that
you collaborate with us right now when completing this form. It is necessary that great care should be taken in supplying
the information set out below and the statements given should be strictly accurate, irrespective of whether the facts are in
your favour or otherwise.

You should not make any payment offer or promise of any payment or admit liability in any way, as by so doing
you may prejudice your position and make settlement a difficult matter.
If you have received any communications, verbal or written, please inform us forwarding all letters, etc, without
replying thereto. Please note that the issue of this form is not an admission of liability on the part of the Corporation.

With regard's
Ethiopian Insurance Corporation

Branch claim to be submitted.
Name in full
Address Phone No.
POLICY NO. Renewal Date
Make Year of Manufacture Registered Letter & No.
C.C. For what purpose is it being used Carrying Capacity & Type
Name in full Phone No.
Occupation Age.
License No. Grade Expiry Date
Date Time Place
What was the speed of the vehicle? How far was it from near side?
Was horn sounded properly Were you in the vehicle? Yes No
Description of the accident (explain conditions of road, weather and visibility)
Give name and addresses of Owner and Driver of the Vehicle(s) involved
Who in your opinion is responsible for the accident?
Do you hold more than one policy indemnifying you in respect of this accident? if so, give particulars
Does your driver hold a policy other than the above, indemnifying him in respect of this accident? Give details.
Were particulars taken by police? If so, give Police Station, Officers name and identification No.
Give name and addresses of persons who were in your vehicle at the time of accident Name and address of independent witness
    If none taken, please state why?
Details of damage to your vehicle
Details of injuries to persons (give names and addresses of such persons.)
I/we declare the foregoing particulars to be true and correct in every respect, and undertake to render the Corporation every
assistance in my/our power in dealing with the matter.
Driver's Signature Insured's Signature