Motor Claim Declaration Form

By filling this form and pressing the send button at the bottom of the page, you give us the right to pay your liability toward the third party.

If you need any further assistance, check the Frequently Asked Questions page, e-mail the claim department or give us a call, and we will be pleased to help you.

PS: Fields marked with a (*) are required.
Victoire Insured Name *
Address
E-mail *
Phone Number
Policy Number *
Car type
Year of make
Plate Number
Expert Name
Driver name at time of accident
Driver Permit Number
Permit Date of Issuing	dd/MM/yyyy
Permit Expiry Date	Expiry
Date & Time of accident	dd/MM/yyyy HH:MM
Place of accident
Description of How the Accident Occurred
Third Party Name
Insured with
Address
E-mail
Phone Number
Policy Number
Car type
Year made
Plate Number
Third Party Expert Name
Driver name at time of accident
Name of the third party injured (if any)
Name of the Hospital
Please send us a copy of the police investigation Report

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