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Motor Claim Form Final
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MOTOR CLAIM NOTIFICATION FORM
Date of the accident
*
Time
*
12
1
2
3
4
5
6
7
8
9
10
11
:
00
10
20
30
40
50
AM
PM
Did you or anybody else get injured? (If yes, see “IN CASE OF INJURY”)
*
Yes
No
Place of the accident
*
Weather & road conditions
*
Police man
No.:
Police Station
Telephone
Independent witnesses:
Name
Telephone
Age
Address
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